Extracorporeal photopheresis is a second-line treatment for a variety of oncological and autoimmune disorders that is performed in the hospital inpatient, hospital outpatient, and Critical Access Hospital (CAH) settings. In the procedure, some of a patient’s removed white blood cells are exposed first to the drug 8-methoxypsoralen (8-MOP) and then to ultraviolet A (UVA) light. After UVA light exposure, the treated white blood cells are re-infused into the patient, stimulating their immune system in a series of cascading reactions. This activation of the immune system then impacts the illness being treated.
Currently, Medicare covers extracorporeal photopheresis for the following indications:
• Palliative treatment of skin manifestations of CTCL that has not responded to other therapy;
• Patients with acute cardiac allograft rejection whose disease is refractory to standard immunosuppressive drug treatment; and
• Patients with chronic graft versus host disease whose disease is refractory to standard immunosuppressive drug treatment.
Effective for claims with dates of service on and after April 30, 2012, Medicare will cover extracorporeal photopheresis for the treatment of Bronchiolitis Obliterans Syndrome (BOS) following lung allograft transplantation, but only when provided under an approved clinical research study that meets specific requirements to assess the effect of extracorporeal photopheresis for the treatment of BOS following lung allograft transplantation
Effective for claims with dates of service on or after April 30, 2012, Medicare contractors will accept and pay for hospital outpatient and physician claims containing HCPCS procedure code 36522 along with one of the following ICD-9-CM codes
491.20 Obstructive chronic bronchitis without exacerbation
491.21 Obstructive chronic bronchitis with (acute) exacerbation
491.9 Unspecified chronic bronchitis
496 Chronic airway obstruction, not elsewhere classified
996.84 Complications of transplanted lung
V70.7 Examination of participant in clinical trial
Claims must also contain all of the following:
Diagnosis code V70.7 (as secondary diagnosis).
Condition code 30 (institutional claims only).
Clinical trial modifier Q0 (Investigational clinical service provided in a clinical research study that is in an approved research study).
Value code D4 with an eight-digit clinical trial number (optional) (fiscal intermediary only).