# Chemotherapy with Evaluation and Managment



## alannae (Jan 18, 2013)

I have been scouring the internet for resources to help me determine the guidelines for documentation and billing E&Ms on the same DOS as chemotherapy. I have read through 30.6.7 of Medicare Claims Processing Manual (Chapter 12) http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf :

_D Drug Administration Services and E/M Visits Billed on Same Day of Service
Carriers must advise physicians that CPT code 99211 cannot be paid if it is billed with a drug administration service such as a chemotherapy or nonchemotherapy drug infusion code (effective January 1, 2004). This drug administration policy was expanded in the Physician Fee Schedule Final Rule, November 15, 2004, to also include a therapeutic or diagnostic injection code (effective January 1, 2005). Therefore, when a medically necessary, significant and separately identifiable E/M service (which meets a higher complexity level than CPT code 99211) is performed, in addition to one of these drug administration services, the appropriate E/M CPT code should be reported with modifier -25. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required._

And this document from ASCO:
http://www.asco.org/ASCOv2/Departme...oding with Drug Infusion Services 3-10-10.pdf


My understanding is that certain things are included with the RVUs for the infusion codes and they should not count towards the E&M. What is included? What constitutes a "separately identifiable office or other outpatient E/M service" in this situation?

What I have been doing when I review documentation is eliminating things that are necessary to be able to proceed with chemo when I 'grade' the E&M (review of blood counts to show patient is able to get chemo that DOS, review of orders, review of minor/expected side effects, etc). IS this an accurate list of what is included in the infusion codes? What all is included? 

Should those things be eliminated in the calculation of the E&M level? Or can they be used for the E&M even though they are considered part of the infusion service?

I would really like to see more discussion on this topic. The instructions/documentation I have been able to find seem very vague. And I have a feeling that the E/M and its documentation is going to become a source of headaches for providers in the near future.

Alanna


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## traci.susong@gmail.com (Jan 19, 2013)

physicians office or facility? If facility I can help you. email me at susongt@summahealth.org


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## ivd34769 (Jan 20, 2013)

I had that same question a long time ago, it is kind of frustrating actually... specially when some of the services bundle or are inclusive.  In our office we do not bill the e/m code unless is a level 2 or higher and put a 25 modifier, a 99211 gets bundled with the chemotherapy infusion.  Not long ago we had a private audit to make sure we were doing things correctly as far as our infusion, billing, etc. and were told by the auditor whom is part of OMF (Oncology Managers of Florida) that it's futile to bill a nurses visit when chemotherapy is being administered due to it being looked at as inclusive, which we don't bill anyways due to this . I want to pull my hair as well when chemotherapy is held due to low counts and blood had been taken from port because the only thing you can bill is the labs through port code (36591) and the cbc; the nurse assessment gets bundled with the 36591 so there is not much one can do unless the patient is seen by the physician for more detailed assessment and the 36591 gets bundled with the physicians visit, no way of winning...


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## alannae (Jan 22, 2013)

I'm looking for information strictly for physician billing (in the office). Although, I am curious as to how it would differ with facility billing.

We don't bill 99211 ever with chemo. I'm looking for information on what part of a physician's notes/visit would be considered bundled into the chemotherapy administration codes. 

I guess I'm wondering if others who are coding E&Ms with chemo are including everything the physician documents when determining the level of E&M. Or if there are certain things they exclude, like looking at basic labs since they would do that anyway before chemo (if not seen face-to-face).

I have one physician who often wants to code a 99212 in addition to chemo but I'm not sure if his documentation warrants that.


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## admiller04@gmail.com (May 20, 2013)

*E/M on same day as chemo*

Hello!

Physicians can bill an E/M visit on the same day as chemotherapy. The recommendation would be to have the evaluation and management service provided on a separate DOS from the procedure (chemo, ect.). By doing this, it would alleviate the need for the modifier 25.  Because the OIG has a focus on the over utilization of the modifier 25 providers should use with caution. I've seen this issue go both ways. Some providers prefer to schedule a patient's E/M one day and chemo the next to avoid any potential audits. However, others still prefer to see patient's the same day as chemo to assess any possible problems the patient may be having prior to giving chemo. A lot of what I tend to see is simply physician preference, right or wrong. In the event, providers tell say they insist on seeing their patients for a follow up prior to giving chemo on the same day, I always stress the importance of the documentation to support that particular visit. Because the definition of the modifier 25 is a significant, separately identifiable evaluation and management (E/M) service by the physician on the day of a procedure, the provider would need to append the modifier 25 to the E/M service. The providers must also be able to document clearly the reason why the visit is warranted.  The modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed. So if the patient comes in and has a new complaint or issue prior to receiving chemo, the physician can then bill an E/M with the modifier 25 and detail out the issue in his/her documentation.  

Also, for the 99211, the nursing staff would need to be providing services that are over and beyond what the patient came in for. So if the patient was strickly being seen for the chemo that would not warrent the nurse to charge a 99211 because everything is included within the chemo charges. However, if the patient is there for chemo and have a complaint or a new problem needs to be addressed that is seperate from the initial reason for the visit they can charge a 99211-99215.

Hope this is helpful. 

Ashley Miller, CPC, CHONC, CPPM
Consultant 
Revenue Cycle Inc.


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## SThebarge (Jun 17, 2013)

*E&M visits same day as Chemo*

A great improvement in your documentation is the need to assess toxicities and management of their signs and symptoms during chemo.  We as a practice see patients regularly on the same day as chemo, but our physicians are prudent to documenting the need for the service.  They are not just stating reviewed labs, continue with chemo.  There needs to be an assessment of the patient's progress and status.  And when auditing my physicians I do take all of their work from the note into consideration.  What is included in the chemo administration is limited, so if the physician feels the need to see that patient the same day as chemo, then I use everything they document.  If your physician is billing a 99212, just because he/she needed to review the labs and proceed with chemo, that really doesn't constitute a separate and identifiable service.  I would recommend that you have them add key phrases in their documentation, like I stated above.  Usually patient's that need to be seen, are being seen for their toxicities, or dehydration issues, or neuropathy, etc.  I instruct my physicians to utilize the additional diagnosis codes to support the need for the service.  I don't think every patient that comes in for chemo, needs to be seen by the physician prior to.  But the physician does need to follow up with patients during their cycles to assess toxicities.  
I hope this helps you in your practice.
Feel free to email me with additional questions.


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## ljulien (Oct 23, 2013)

Stephanie,

If your office treats Heme patients, how does your office handle phlebotomy & E/M on same day?


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## alannae (Oct 28, 2013)

We don't do phlebotomy in the office. They are sent to the hospital for that. But I would think that if the phlebotomy is pre-scheduled, then the E/M would likely not be separately payable unless there are additional problems being addressed. If the determination to perform the phlebotomy is made during a E/M, then, I think, both codes should be billable.

I'm still working on wrapping my head around the idea of what to do with E/M and procedures done on the same DOS. It just seems so subjective and 'squishy'. What I've been telling my physicians is that if they visit with the patient JUST to determine if they are able to receive today's chemo (ie review labs, etc), then it is not separately payable. But if the visit includes more than that (addressing side effects, reviewing radiology, etc), then it can be coded/billed separately.

Any feedback anyone would like to give? I'm open to all opinions!


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## jlb459 (Nov 20, 2013)

alannae - 

I have to completely agree with you. I am in the hospital setting. However, our Heme/Onc Clinic is considered outpatient. Chemo/Infusions encounters have already been deceided upon from a previous E/M visit. So when the patient comes in for these services I do not charge for an E/M visit. Same goes for the plebotomy. The decesion for this procedure is made a head of time, therefore the day of the phlebotomy no other decision needs to be made unless a complication for the previous E/M visit has arose.


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## swilliams (Dec 17, 2013)

I have a question regarding Chemo admin same day as E/M- What level of risk do you allow for chemo admin?  We are having discussion about this at work.  If you have any Documentation Guidlines you could refer to that would be great.

Thanks,

Shelley


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## thompson12 (Feb 14, 2014)

Allanna,

Regarding your question regarding chemo and E/M on the same day, you probably have come to some settlement but wanted to offer an article that is excellent.  If you want to send me your fax number I would be happy to send to you.  It is a totally pro billing the E/M with infusion and why.  Also, I noticed a consultant in the thread said to bring the patient in on a different day, while this would work but it is considered unbundling and looked at as fraud per several insurance carriers.  I code for Infectious Disease and Onc/Hem.  Stephanie


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## tmenard (Jun 4, 2014)

HI Steph. I am hoping you can help. Provider-Based Oncology Clinic. The facility is trying to bill for and E/M level or HCPCS code when there is no physician seeing the patient. All the staff would do is Vitals , Make sure the labs are documented in the chart then the patient is set to start infusion. Do you have any kind of information on Provider Base Clinic and what documentation the facility needs to be able to bill for the E/M or HCPCS code.
Thanks 
Trish Menard
CPMA,CCS-P, CPC, tntmenard@msn.com


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## sriese (Apr 2, 2015)

*Chemotherapy billing.*

Medicaid is dening our physicians charges. He is a University employee that sees patients at an OP clinic for Oncology on hospital campus. The chemo is administered by hospital nurses. So they are getting paid and sending us a denial. Should we append modifier 25 to the E/M?


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## acw (Apr 7, 2015)

I just answered this same question in another post from 3/24/15.  Here is the information from CMS. I code for a free-standing infusion center, and when the patient has side effects of chemo, abnormal labs, changes in medication regimen, etc., and the physician changes things or treats side effects, we do code/bill for an E/M with a -25 modifier appended to it.  from a billing standpoint, we have not had denials on most of these.  We have also appealed the ones that were denied and do get reimbursement most of the time.  The key is medical necessity for the visit over and above the chemo/infusion session.  If nothing has changed, no side effect, no abnormal labs then we do not bill an E/M for that date of service.  Hope this helps.
Annette W. CPC, CEMC

CMS Claims Processing Manual 100-04
Chapter 12 - Physicians/Nonphysician Practitioners
30 - Correct Coding Policy
30.5.F
Chemotherapy Administration (or Nonchemotherapy Injection and Infusion) and Evaluation and Management Services Furnished on the Same Day
For services furnished on or after January 1, 2004, do not allow payment for CPT code 99211, with or without modifier 25, if it is billed with a nonchemotherapy drug infusion code or a chemotherapy administration code. Apply this policy to code 99211 when it is billed with a diagnostic or therapeutic injection code on or after January 1, 2005.
Physicians providing a chemotherapy administration service or a nonchemotherapy drug infusion service and evaluation and management services, other than CPT code 99211, on the same day must bill in accordance with ?30.6.6 using modifier 25. The carriers pay for evaluation and management services provided on the same day as the chemotherapy administration services or a nonchemotherapy injection or infusion service if the evaluation and management service meets the requirements of section ?30.6.6 even though the underlying codes do not have global periods. If a chemotherapy service and a significant separately identifiable evaluation and management service are provided on the same day, a different diagnosis is not required.In 2005, the Medicare physician fee schedule status database indicators for therapeutic and diagnostic injections were changed from T to A. Thus, beginning in 2005, the policy on evaluation and management services, other than 99211, that is applicable to a chemotherapy or a nonchemotherapy injection or infusion service applies equally to these codes.


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