Effective for dates of services on and after December 19, 2006, Medicare has expanded coverage for extracorporeal photopheresis for patients with acute cardiac allograft rejection whose disease is refractory to standard immunosuppresive drug treatment and patients with chronic graft versus host disease whose disease is refractory to standard immunosuppresive drug treatment.
Healthcare Common Procedural Coding System (HCPCS), Applicable Diagnosis Codes and Procedure Code
The following HCPCS procedure code is used for billing extracorporeal photopheresis
• 36522 – Photopheresis, extracorporeal
The following are the applicable ICD-9-CM diagnosis codes for the new expanded coverage:
• 996.83 – Complications of transplanted heart, or
• 996.85 – Complications of transplanted bone marrow.
Remittance Advice Remark Codes (RAs) and Claim Adjustment Reason Code
Contractors shall continue to use the appropriate existing messages that they have in place when denying claims submitted that do not meet the Medicare coverage criteria for extracorporeal photopheresis.
Contractors shall deny claims when the service is not rendered to an inpatient or outpatient of a hospital, including critical access hospitals (CAHs) using the following codes:
• Claim Adjustment Reason code: 58 – “Claim/service denied/reduced because treatment was deemed by payer to have been rendered in an inappropriate or invalid place of service.”
• MSN 16.2 – “This service cannot be paid when provided in this location/facility.” Spanish translation: “Este servicio no se puede pagar cuando es suministrado en esta sitio/facilidad.” (Include either MSN 36.1 or 36.2 dependant on liablity.)
• RA MA 30 – “Missing/incomplete/invalid type of bill.” (FIs and A/MACs only)
• Group Code – CO (Contractual Obligations) or PR (Patient Responsibility) dependant on liability.
