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 [...]