June 27, 2016

Stem Cell Transplants and ICD-10

Hematopoietic stem cells (HSCs) are produced in bone marrow. These stem cells are responsible for the constant renewal of blood, with the production of billions of blood cells every day.

What is amazing about an HSC is the fact that it can differentiate itself into a variety of cells. An HSC may differentiate into a myeloid progenitor cell or a lymphoid progenitor cell. The myeloid progenitor cells may become neutrophils, basophils, eosinophils, monocytes, macrophages, platelets, or red blood cells. The lymphoid progenitor cells become B or T lymphocytes.

When patients are found to have certain cancers such as leukemia, multiple myeloma, some types of lymphoma, or even blood (severe aplastic anemia) or immune system disorders, they may undergo stem cell transplants.

In the past, patients underwent a bone marrow transplant (BMT), which was done to replace damaged or destroyed bone marrow with healthy bone marrow stem cells. Patients either underwent autologous (AUTO transplant, where the donor and recipient are the same person) or allogeneic (ALLO transplant, where the donor and recipient are different individuals) transplants.

These procedures were called bone marrow transplants because the stem cells were collected from the bone marrow. In the past, physicians performed bone marrow transplants by anesthetizing the stem cell donor, puncturing a bone such as a hipbone (iliac crest) or sternum, and drawing out the bone marrow cells with a syringe. Physicians now prefer to harvest donor cells from peripheral circulating blood. Aphaeresis (Greek for “a taking away”) is another term utilized for the collection of peripheral blood stem cells, which are then frozen and given back to the patient after intensive treatment.

Since the procedure today collects stem cells from blood, the term now utilized is a “stem cell transplant.” Often the term rescue is used instead of transplant. The donor is injected with a cytokine, such as a granulocyte-colony stimulating factor (GCSF), a few days before the cell harvest. To collect the cells, a physician will insert an intravenous tube (transplant catheter) into the donor's vein and pass his or her blood through a filtering system, collecting the white blood cells (CD34+) and returning the red blood cells back to the donor.

With umbilical cord transplants, stem cells are taken from and immediately after delivery of an infant. These stem cells reproduce into mature, functioning blood cells quicker and more effectively than stem cells taken from the bone marrow of another child or adult. The stem cells are tested, typed, counted, and frozen until they are needed for a transplant.

A “biopsy” has the following definitions:

• The removal of a small piece of tissue for laboratory examination;

• A sample of tissue taken from the body in order to examine it more closely;

• A procedure to remove a piece of tissue or a sample of cells from your body so that it can be analyzed in a laboratory; or

• The removal of cells or tissues for examination by a pathologist.

In the 2016 ICD-10-PCS Official Guidelines for Coding and Reporting, Guideline B3.4a for biopsy procedures notes:

Biopsy procedures are coded using the root operations excision, extraction, or drainage, and the qualifier diagnostic. Examples: Fine needle aspiration biopsy of lung is coded to the root operation drainage with the qualifier diagnostic. Biopsy of bone marrow is coded to the root operation extraction with the qualifier diagnostic. Lymph node sampling for biopsy is coded to the root operation excision with the qualifier diagnostic.

The root operation for bone marrow biopsy procedure is extraction since the main objective is to pull out a portion of the bone marrow. The Alphabetic Index entry main term extraction, subterm bone marrow, refers the coding professional to Table 07D. Biopsy of bone marrow is coded with the qualifier diagnostic. A hollow needle is inserted into the bone. The needle is then twisted and advanced. This motion allows a sample of bone marrow to enter the core of the needle.

The qualifier diagnostic is used to identify drainage procedures that are biopsies, per coding guideline B3.4a.The approach is percutaneous because a puncture is made to accommodate insertion of the biopsy needle.

The ICD-10-PCS code for this procedure is 07DR3ZX. The fourth character (R) identifies the body part as bone marrow, iliac.

The root operation in ICD10-PCS for therapeutic plasmapheresis is pheresis (extracorporeal separation of blood products). This can be found under extracorporeal therapies root operations, character 6. If a patient is undergoing a single plasmapheresis, the code assigned would be 6A550Z3. The seventh character captures the blood product that is being extracorporeally separated. As you can see, the options for the qualifier (seventh character) are: erythrocytes (0), leukocytes (1), platelets (2), plasma (3), stem cells, cord blood (4), or stem cells, hematopoietic (5).

According to the ICD-10-PCS guidelines, the putting in of autologous or nonautologous bone marrow, pancreatic islet cells, or stem cells is coded in the administration section. Therefore, in coding a non-autologous bone marrow (BM) transplant via CVP line, the code would be 30243G1, where the first character 3, identifies the administration section.Character 2, body system, will becirculatory (0), the operation is transfusion, and the CVP line will be placed in the peripheral vein, hence the body system/region character 3. The approach will always be percutaneous (3) and the substance is bone marrow (G) and the qualifier 1 for non-autologous.

Reference: 2016 CMS PCS Code table and Index https://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-PCS-and-GEMs.html
Denise M. Nash, MD, CCS, CIM

Denise M. Nash, MD, CCS, CIM, serves as vice president of compliance and education for MiraMed Global Services and as such she handles all Compliance and Education needs including migration to ICD-10. She has more than 20 years experience in the healthcare industry. Dr. Nash has worked for CMS in hospital auditing and has expertise in negotiation and implementation of risk contracting for managed care plans. She has also worked with individuals as well as physician groups on utilization and PQRS management to improve financial performance for the risk-based contracts and value based purchasing (VPB) programs. Her past experience also included consulting for the Office of the Inspector General of New Hampshire in its Fraud and Abuse Division.

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