How to bill for advanced prostate cancer immunotherapy


Here are billing specifics for sipuleucel-T (Provenge) that you need to know.

A It is true that a new code was re-leased for payment of the new prostate cancer treatment known as sipuleucel-T (Provenge) for use on claims on or after July 1, 2011. The code is Q2043 (sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion).

CMS has developed the code and the reimbursement to include the required preparation of the infusion, the cost of the infusion, and the actual immunotherapy cost. The coding was approached this way as the manufacturer has priced the drug to include the preparation of the immunotherapy (leukapheresis), which is arranged and paid for by the manufacturer, as well as the delivery of the infusion immunotherapy to the physician office. The physician office is then responsible for infusion of the immunotherapy to the patient, proper billing of the service, and collection from payer and patient. The Q2043 with appropriate diagnosis codes are reported on the date the infusion is provided. The process is repeated for a total of three infusions.

As the immunotherapy is patient specific, the preparation of the immunotherapy and shipping will need to be coordinated with the patient to make certain the patient presents for infusion. The manufacturer will invoice the physician after the immunotherapy is started for each patient infusion. You will need to bill primary insurance and determine patient responsibility or secondary coverage.

As of early August, we have not obtained coverage information for any private payers. Check with private payers prior to scheduling this service for a non-Medicare patient.

Q Our office has a computed tomography scanner. The new code introduced this year for the combination abdomen and pelvis has been a significant income loss. We have heard from other groups that they are still billing services for private-sector payers separately under the abdominal CT code and the pelvic CT code and are being paid for both. Is this correct?

A No, that would be incorrect billing. CPT coding conventions state that you should use the most accurate code available for services provided. Unless you have written directions from the payer to do otherwise, you should bill the new code for both services if both the abdomen and pelvis are scanned. The fact that others state that they are being paid for both may or may not be accurate, and even if they are being paid, it would be incorrect and may require a take-back in the future.

Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook. Mark Painter is CEO of PRS Urology SC in Denver.

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