# E/M & injection or malignant destruction?



## JesseL (Dec 14, 2013)

Would the note below justify the use of modifer 25 since the physician did more than just an injection?  Detailed history and expanded problem focus exam documented.  99202-25 & 11900 or should this be considered a malignant destruction? 17276?

Medical Decision Making: Squamous cell carcinoma of scalp 
POC: Recommendation is Malignant destruction of SCC. Confirmed bx x2 by pt's former dermatologist,
Dr. X, to be invasive squamous carcinoma. Explained that the tumor is too large for us to operate.
Patient and patient's family also denies that they want to proceed with surgery especially d/t patient's
advanced age. 5-fluorouracil x 2.0cc injected into tumor. Explained that treatment may only slow down the
growth but may not take it away completely like an excision would do. Advised pt to RTC in 3 weeks.


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## OCD_coder (Dec 14, 2013)

CMS and a few MAC's have written guidelines that New patient visits are exempt from the Mod-25 rules (Palmetto).  Thier rationale is that an E&M is appropriate obtain new history and to determine the course of treatment since they have never been seen by a provider before supports a modifier 25.  The procedure you are looking for falls into this code set:  96405 - 96406

96405  Chemotherapy administration; intralesional, up to and including 7 lesions


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## JesseL (Dec 14, 2013)

OCD_coder said:


> CMS and a few MAC's have written guidelines that New patient visits are exempt from the Mod-25 rules (Palmetto).  Thier rationale is that an E&M is appropriate obtain new history and to determine the course of treatment since they have never been seen by a provider before supports a modifier 25.  The procedure you are looking for falls into this code set:  96405 - 96406
> 
> 96405  Chemotherapy administration; intralesional, up to and including 7 lesions



oh wow I had no idea that code existed. Thank you!

Is it okay to bill 99202 with 96405 in this case?


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## Peter Davidyock (Dec 15, 2013)

OCD Coder,

I read that as well. Palmetto is my MAC so I tried it. Every single NP E/M I submitted with a procedure was denied as bundled. I quickly reverted to using the 25. I think that although they have made this statement the edit has no been updated. Sort of like the level one level two critical care update released last April that states a different provider can bill level two on the same day so long as they are the same group/specialty.
The rule is in place but the edit has not been updated.


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## JesseL (Dec 15, 2013)

I'm a bit confuse because the CPT book says 96405 is for treatment of non cancer diagnosis.  This is a squamous cell carcinoma so does that mean I can't use this code since it's a cancerous diagnosis??


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## jmessick (Jan 9, 2014)

Would you be able to post the thread to the CMS website that has the information regarding new patient is an exemption to the Modifier 25 usage.


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## OCD_coder (Jan 9, 2014)

My CPT book by the AMA does not state "non-malignancy" in the description so I am not sure where the failure is for us.  Yes, you can use the code.

Here is the lay description for the 96405:
The physician or supervised assistant prepares and administers medication to combat diseases such as malignant neoplasms or microorganisms. Report 96405 when medication is injected directly into the lesion, up to and including seven lesions. Report 96406 when more than seven lesions are treated. 
-not sure what book you have, but it should be used with patients with malignancy/cancers.

I would support a separate E&M with the assessment as they are discussing with the family options for treatment and surgery was discussed but not selected.

Oceanlivin, I agree with you - updates or information at times aren't really correct/accurate as we understand coding rules.  Based on the CMS NCCI Policy Manual a modifier 25 would be required on the E&M with this code set identified here, as it has the global status code is 000, otherwise it will get denied as you found out.  Frustration I know.

Palmetto Modifier 25 Rules:
http://www.palmettogba.com/palmetto/webTool.nsf/vTool/mod25


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## jmessick (Jan 13, 2014)

Thanks for the link.  This is the best breakdown I have seen.  Although our practice is looking at this as:

If there is a seperate identifiable E/M you would not use the modifier 25 for new patients not that they are exempt from this ruling.  If your procedure has 0 or 10 day global the amout of the procedure includes the E/M portion therefore not payable as indicated in this link.  

On visits our docs sees a new patient does a detailed skin exam and performs a biopsy and we are not abe to bill a NP visit as it is included in the biopsy. I am on a neverending search for documentation to prove this wrong!


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## JesseL (Feb 6, 2014)

OCD_coder said:


> My CPT book by the AMA does not state "non-malignancy" in the description so I am not sure where the failure is for us.  Yes, you can use the code.
> 
> Here is the lay description for the 96405:
> The physician or supervised assistant prepares and administers medication to combat diseases such as malignant neoplasms or microorganisms. Report 96405 when medication is injected directly into the lesion, up to and including seven lesions. Report 96406 when more than seven lesions are treated.
> ...



I use a AMA CPT 2013. Page 393 says :Chemotherapy admistration codes 96401-96549 apply to parental administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer diagnosis"

Which is why I'm confused because it is a cancer diagnosis?


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## CatchTheWind (Feb 7, 2014)

What it says is that it is ALSO used for treatment of non-cancer diagnoses.  So it can be used both for cancer diagnoses and also for certain non-cancer diagnoses.  (In CPT 2014 this is on page 412.)


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## JesseL (Sep 30, 2014)

CatchTheWind said:


> What it says is that it is ALSO used for treatment of non-cancer diagnoses.  So it can be used both for cancer diagnoses and also for certain non-cancer diagnoses.  (In CPT 2014 this is on page 412.)



I'm having second thoughts about this.  

Isn't injecting 5FU to a SCC consider chemical destruction and should be coded with the 172xx codes?


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## mitchellde (Oct 1, 2014)

No it is not a destruction in the case originally posted as the tumor was not destroyed.


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## JesseL (Oct 1, 2014)

mitchellde said:


> No it is not a destruction in the case originally posted as the tumor was not destroyed.



but they're doing it to slow down the growth of the scc tumor and also at the same time hope that  the 5fu injections will make it fall off eventually.  The patient has been doing the injections the past 6 to 8 visits and I've been billing it as 96405 and recently part of it did fall off on it's own due to the treatment.


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## JesseL (Oct 1, 2014)

JesseL said:


> but they're doing it to slow down the growth of the scc tumor and also at the same time hope that  the 5fu injections will make it fall off eventually.  The patient has been doing the injections the past 6 to 8 visits and I've been billing it as 96405 and recently part of it did fall off on it's own due to the treatment.



If the provider is injecting it more aggressively hoping that the tumor would fall off, would that be chemical destruction?

Would the "aim" be the deciding factor? Being that the provider is using 3 syringes of 5fu on the tumor this time hoping it will fall off with the treatment.


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