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June 22, 2009

Coding for Immunotherapy
For The Record
Vol. 21 No. 13 P. 27

Immunotherapy is a relatively new type of therapy that uses a patient’s immune system to fight disease. It protects the body against cancer, as well as combats cancer that has already developed. Also called biologic therapy or biotherapy, immunotherapy can be used alone or with other treatments.

There are two main types of immunotherapy: active and passive. Active immunotherapy stimulates the body’s immune system to fight the disease. Passive immunotherapy uses immune system components made in a lab.

Monoclonal antibodies (MoAbs or MAbs) are a type of passive immunotherapy and the most widely used form of cancer immunotherapy. FDA-approved MAbs to treat cancer include the following:

• rituximab (Rituxan), ibritumomab tiuxetan (Zevalin), and tositumomab (Bexxar) — treat non-Hodgkin lymphoma;

• trastuzumab (Herceptin) — treats breast cancer;

• gemtuzumab ozogamicin (Mylotarg) — treats acute myelogenous leukemia;

• alemtuzumab (Campath) — treats chronic lymphocytic leukemia;

• cetuximab (Erbitux) — treats colorectal and head and neck cancers;

• bevacizumab (Avastin) — treats colorectal, non–small-cell lung, and advanced breast cancers; and

• panitumumab (Vectibix) — treats colorectal cancer.

Cancer vaccines are meant to have the immune system attack a disease that already exists. They are considered active immunotherapy because they trigger the immune system to only affect the cancer cells. Currently, there are no cancer vaccines approved in the United States to treat cancer.

Lymphokine-activated killer (LAK) cell therapy tries to boost specific parts of the immune system. It uses interleukin-2 (IL-2) to treat killer T cells. These cells are then injected back into the patient and are now called LAK cells. LAK cell therapy is being tested to treat melanoma, brain tumors, and other cancers.

Immune system cells found deep inside some tumors are called tumor-infiltrating lymphocytes. They are removed and treated with IL-2 before being injected back into the patient to become active cancer fighters.

Cytokines are chemicals made by immune system cells and mainly used in cancer treatments to lessen the side effects of chemotherapy. Common cytokines include the following:

• ILs act as chemical signals between white blood cells. IL-2 is used to treat advanced kidney cancer and metastatic melanoma. They help immune system cells grow and divide more quickly.

• Interferons (IFNs) help the body resist viral infections and cancers. Currently, there are three types of FDA-approved IFNs: alpha, beta, and gamma. IFN-alpha is the only one used to treat cancer, including hairy cell leukemia, chronic myelogenous leukemia, follicular non-Hodgkin lymphoma, cutaneous T-cell lymphoma, kidney cancer, melanoma, and Kaposi sarcoma.

• Granulocyte-macrophage colony-stimulating factor causes the bone marrow to make more of certain types of immune system cells and blood cells.

Assign ICD-9-CM code 99.28 for any immunotherapy agent injection except for IL-2, which is classified to 00.15.

ICD-9-CM Coding Guidelines
Admission for immunotherapy is classified to code V58.12, which will be sequenced as the principal diagnosis. This code is used if the treatment is directed toward a neoplastic condition. If the immunotherapy is used to treat a non-neoplastic condition, sequence the condition as the principal diagnosis and do not assign code V58.12 per the excludes note under subcategory V58.1. The following are common sequencing guidelines pertaining to immunotherapy:

• When a patient is admitted for the sole purpose of immunotherapy and develops complications after admission, such as nausea or vomiting, the principal diagnosis is V58.12 followed by any codes for the complications.

• When the admission is for the treatment of anemia or dehydration due to chemotherapy or immunotherapy, the anemia or dehydration will be sequenced as the principal diagnosis.

• When the admission is to determine staging, the malignancy will be sequenced as the principal diagnosis even if immunotherapy is administered.

• When the admission involves the surgical removal of a malignancy, the malignancy will be sequenced as the principal diagnosis even if immunotherapy is administered.

Coding and sequencing for immunotherapy are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.