Oncology & Hematology Coding Alert

Here’s how ethically reported critical care services can add $282 to your bottom line.

If your oncologist has to step in to treat a patient’s adverse reaction to chemotherapy, be sure the physician documentation contains the information to support the treatment and rationale to capture all Medicare reimbursement for the visit and any procedural services.

To claim all of your practice’s rightful dollars, keep your eyes peeled for the three circumstances below when you may report an E/M code in addition to infusion admin codes.

Circumstance 1: Report Infusion Code + Adverse Reaction E/M

If a patient has an adverse drug reaction during a chemotherapy session and the physician intervenes, report the appropriate office visit E/M code based on the services provided (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...), states MLN Matters article SE0462. As there are a number of different and new medications used in oncology, anaphylactic reaction to the chemotherapy drugs may be the most common emergency oncology practices encounter.

Key point: You should report the E/M code in addition to the infusion admin code(s) and expect payment for both. CPT^®’s injection and infusion guidelines support this method by stating, “If a significant, separately identifiable Evaluation and Management service is performed, the appropriate E/M service should be reported using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) in addition to 96360-96549.” Codes 96360-96549 encompass the “Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration” subsection.

Example: During chemotherapy infusion, a patient becomes ill after 46 minutes of infusion time. The staff stops the infusion and calls in the oncologist for treatment. The severity of the reaction makes the E/M service necessary. You report the infusion using 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug). Claim the E/M using 99212-99215 (Office or other outpatient visit …) and append modifier 25 to the visit. If the patient’s reaction is severe and requires admission to the hospital, other codes for the admission may be more appropriate.

Money talks: Properly catching this E/M in the office setting and assuming the patient is managed while in the office would add approximately $56-183 to your bottom line, according to Medicare’s non-facility national rates for CPT^® codes 99212-99215.

Circumstance 2: Total Time E/M for Pre-Session E/M, Too

If the oncologist sees the patient before the chemotherapy session for a problem unrelated to admin supervision and also must intervene because of a significant adverse drug reaction, choose the E/M level based on the “total time, resources, and complexity of the physician’s interaction with the patient,” the MLN Matters article states.

Example: An established patient presents for chemotherapy. Upon arrival, she complains of fatigue over the last month, and the oncologist evaluates and manages the fatigue. Later during the same encounter date, the patient receives her scheduled chemotherapy infusion and develops an adverse reaction requiring the oncologist to assess and respond to the condition. As an example, perhaps the notes for the two services considered together qualify for a level-four office visit, so you report 99214-25 (Office or other outpatient visit for the evaluation and management of an established patient ...) in addition to the appropriate chemotherapy admin code(s). Adding the services to choose this higher-level code brings in approximately $131, based on Medicare’s non-facility national rate.

Don’t overlook: Suppose the visit required an extensive amount of time, such as in the below example:

Example: The oncologist documents a 70-minute visit and the reason this patient required additional time. The medical necessity level for the visit meets 99214’s criteria. This level E/M visit typically requires “25 minutes face-to-face with the patient and/or family,” according to the code’s descriptor. In this example, the 70 minutes spent is 45 minutes more than the typical time requirement of 99214, so this visit would be eligible for an additional prolonged service code. Report +99354 (...first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]) with 99214-25 and the infusion code(s). Adding +99354 ($129) to 99214 ($131) will nearly double your E/M reimbursement, based on Medicare’s national rates.

You would historically report prolonged service add on codes +99354-+99355; however, everything has changed in 2021! There are new codes, and to complicate this further, specific rules have been published by Medicare to use codes outside of CPT^® to report and calculate the additional time and units, says Leah Fuller, COC, CPC, Senior Consultant of Pinnacle Enterprise Risk Consulting Services, LLC (“PERCS”), an affiliate of Pinnacle Healthcare Consulting, CO.