Oncology & Hematology Coding Alert

Append modifier 25 to the E/M code and keep documentation in support.

The Correct Coding Initiative (CCI) edits version 20.1, which became effective April 1, 2014, introduce bundles that govern reporting of codes for allergy immunotherapy and E/M services when your physician performs these in the same session. Do not forget to check if appropriate modifiers can come to your rescue when you report these serves together.

“Overall, it’s a bit of a yawn this time, which is probably good. There are 4,322 new edit pairs, bringing the total active list to 1,314,537 active pairs,” says Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla. “Nearly 80% of the new edit pairs were defined by the policy statement “CPT® Manual or CMS manual coding instructions.”

Historically, CCI develops its coding conventions based on

• The American Medical Association’s (AMA’s) Current Procedural Terminology (CPT®) manual; 
• National and local policies and edits;
• Coding guidelines developed by national societies; 
• Analysis of standard medical and surgical practice; and 
• Review of current coding practice.

Watch out for E/M and Allergy Code Bundling

If you are looking at reporting any codes from the code range, 95115-95180, for allergy immunotherapy services and procedures along with E/M codes for the same session, don’t forget to check the latest CCI bundles. According to CCI 20.1, you should consider E/M codes bundled into the codes for allergy immunotherapy services. These edits have a modifier indicator of ‘1.’ This means you cannot report the E/M code unless you unbundle it using a suitable modifier, such as 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) with the E/M code. Make sure you have supporting documentation.

“These edits are based on what is in the CPT® manual,” states Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “In the allergen immunotherapy section of CPT®, it states, ‘Office visit codes may be used in addition to allergen immunotherapy if other identifiable services are provided at that time.’ The CCI version 20.1 edits are consistent with that instruction,” Moore points out. 

Some of the E/M codes that face this bundling with allergy immunotherapy codes include:

• Office/outpatient and inpatient problem-oriented 
• E/M codes (99201-99239)
• Consultation codes (99241-99255)
• Emergency department services (99281-99285)
• Critical care codes (99291-99292)
• Nursing care codes (99304-99318)
• Domiciliary, rest home, or custodial (assisted living) care codes (99324-99337)
• New or established home visit codes (99341-99350)
• Prolonged services codes (99354-99360)
• Care plan oversight codes (99374-99378)
• Preventive medicine services (99381-99420)
• Interprofessional consultation codes (99446-99449)
• New born care and inpatient neonatal intensive care services and pediatric and neonatal critical care codes (99460-99486)
• Complex chronic care coordination services (99487-99489)
• Transitional care management codes (99495-99496).

Coding tip: If the evaluation of the patient was directly related to the allergy immunotherapy service or procedure performed and a normal part of that service, you cannot unbundle the evaluation portion using an E/M code and a modifier. In other words, “a patient is evaluated before the allergen injection to ensure that there are no contraindications to administering the injection,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania, Department of Medicine in Philadelphia.  “Additionally, the patient is monitored for a period of time post-injection to assess for any reactions.  Neither of these evaluations can be separately billed.”

However, if the E/M service was significant and separately identifiable from the allergy immunotherapy, you can unbundle it by appending the modifier to the E/M code. Provide adequate documentation supporting the services performed to enable payment for both the codes. “Documentation is a key in this situation,” Moore says. The notes in the chart should clearly establish that the E/M service was significant and separately identifiable from the allergy immunotherapy. One way to reinforce the provider’s thinking is to request the E/M service be documented separately from the note for the allergy immunotherapy perhaps by putting it on a different page, Moore adds. 

Example: Your physician assesses an established patient suffering from cough and fever due to an acute viral condition and the patient receives her scheduled bimonthly allergy immunotherapy for allergic rhinitis due to animal hair and dander (477.2; J30.81 in ICD-10). Your physician performs and documents the E/M service including the necessary components to evaluate and treat the acute condition. 

In this scenario, you may report 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) and 99213 (Office or other outpatient visit for the evaluation and management of an established patient…) along with the modifier 25 appended to 99213.

Since your physician evaluated the patient for a problem that was not related to the allergy immunotherapy services, you are justified in using a modifier to unbundle the codes and claim compensation for both services.

Reminder: CCI 20.1 also has introduced bundles between some of the above mentioned E/M codes and codes for allergy testing procedures, 95004-95071. So, if you are planning to report a code such as 95070 (Inhalation bronchial challenge testing [not including necessary pulmonary function tests]; with histamine, methacholine, or similar compounds) or 95071 (…with antigens or gases, specify) with an E/M code, don’t forget to check CCI for bundling. As you do with allergy immunotherapy codes, you can unbundle the codes by appending the modifier 25 with the E/M code, when appropriate.