Oncology & Hematology Coding Alert

Codes for evaluation and management (E/M) services, 99211-99215, and chemotherapy administration, 96400-96549, are inextricably linked, but that does not mean they should be automatically bundled. Oncology practices often mistakenly bundle these two services when they should be billed separately. By doing so, coders are probably leaving money they deserve on the table.

How chemotherapy-related E/M services are billed depends on the type of payer, says Nanci Giacomozzi, office manager specializing in oncology for P.K Administrative Services, a medical billing firm in Lakewood, Colo. On one hand, Medicare recognizes the need for physicians to continually monitor and manage a patients chemotherapy treatment, allowing them to be reimbursed for both E/M services and administration. Non-Medicare payers, however, are not so enlightened and routinely reject E/M service claims when they are provided on the same day as administration.

The nurse-only visit (99211) is the most common E/M service related to chemotherapy administration. It is also the most misused code in oncology billing, Giacomozzi adds. Many practices use 99211 for visits that dont qualify as an E/M service. For example, it should not used when patients come in to pick up supplies or drugs because there is no exam taking place. This overuse has resulted in increased scrutiny among non-Medicare payers that are now routinely rejecting 99211. This should not, however, deter practices from billing it with every chemotherapy-related E/M visit, Giacomozzi says.

In its publication, Practical Tips for the Practicing Oncologist, the American Society of Clinical Oncology (ASCO) also advises as follows: On days when a patient receives chemotherapy but the physician has no face-to-face contact, the oncologist may report and be paid for incident-to services furnished by employees of the physician in addition to the administration. For example, a common 99211 visit is scheduled with chemotherapy, and the nurse performs an exam, focusing on the patients reaction to previous treatment and documents it in the record. After the completion of the E/M services, the nurse administers the chemotherapy via infusion. Medicare allows oncology practices to bill 99211 separately without having to append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when it is related to chemotherapy administration. (See related article on the suspended CCI edits.)

The visit should be coded as:

96410 (chemotherapy administration, intravenous; infusion technique, up to one hour);
J9000 (doxorubicin HCl 10 mg);
99211;
J2405 (injection, ondansetron HCl, per 1 mg); and
90780 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) if the therapy was administered sequentially to chemotherapy administration.

Billing Non-Medicare Payers

Barbara A. Love, compliance analyst/educator with the University of Rochester Medical Center in Rochester, N.Y. says, It has been my experience that non-Medicare payers do not routinely pay for 99211. She uses a conservative approach with these carriers. Rather than billing for nurse-only services related to chemotherapy, she states practices should only bill E/M codes when they can prove the visit was separate from chemotherapy administration.

Love says, It would be ideal for oncology practices to get instruction from each of their non-Medicare payers on how to bill for chemotherapy-related E/M service, but not all are forthcoming.

Because E/M services are common preludes to administration, it can be difficult to distinguish a chemotherapy-related visit from one that has the markings of a separately identifiable service. Nurses routinely check blood pressure, ask questions, flush or clean ports and prepare the patient for chemotherapy, but these, Love says, are related to the administration and should not be billed separately with 99211.

But, if in that same visit the patient raises additional complaints or exhibits symptoms that require the nurse, mid-level provider or physician to examine the patient and take action, the practice can bill for a separate E/M service, Love says.

She uses the following illustration: The patient arrives for chemotherapy administration. During the course of the nurse-only visit, the patient complains of a severe headache. The symptom prompts the nurse to focus a portion of the visit on the complaint and seek the advice of the oncologist in the office. The physician advises the nurse on treatment, and the chemotherapy is administered as scheduled.

According to Love, the oncology practice in the above illustration should bill 99211 appended with modifier -25. In addition, the claim form should include a diagnosis code for a condition other than cancer to bolster the message that the E/M service was needed for something other than chemotherapy administration. For the illustration provided, 784.0 (headache) should be used.

Ultimately, you should check with your carrier and request guidance regarding its coding preference.

Modifier -25 Required for Higher E/M Services

Code 99211 is not the only E/M service code available when coding for chemotherapy-related E/M services. Higher levels of E/M codes should be considered if the visit called for face-to-face contact with the physician or mid-level provider. Oncology practices should determine the appropriate code based on the presence and nature of the three key components of an E/M visit history, exam and medical decision-making.

As long as they meet the documentation requirements for 99212-99215, Medicare will pay for the E/M service in addition to the chemotherapy administration. Non-Medicare payers will typically not pay for higher-level E/M service related to chemotherapy administration unless modifier -25 is attached to the E/M code, Giacomozzi says.

Documentation should also support the notion that the E/M service was separate from administration. It should show that the physician had face-to-face contact with the patient, what happened during the visit and the time period of the visit. The three key components of an E/M visit should be the driving factors in coding the appropriate level of service.

Also, if more than half of the visit is spent counseling the patient and/or family, the amount of time can be used to determine the level of E/M service. For example: Patient arrived at 9 a.m.; Discussed reaction to last treatment and social issues; Patient complained of headaches; Discussed findings with Dr. Smith Nurse Sally Jones. Discussed history of problem with patient; Examined eye and neurological systems, results of which were negative; Ondansetron given at 10 a.m., completed 10:20 a.m. Doxorubicin started at 10:30 a.m., completed 11:30 a.m. Dr. Smith.

The higher-level visits should also be accompanied by a separate diagnosis code other than cancer to promote the claim that the service was independent of chemotherapy.