Oncology & Hematology Coding Alert

Remember that you don't need two separate diagnoses for chemo plus E/M.

"Seize Every Code When Chemotherapy Results in Adverse Reaction" in Oncology and Hematology Coding Alert, vol. 12, no. 2, discussed CMS's view on coding E/M with chemotherapy, as published in MLN Matters article SE0462 (www.cms.gov/MLNMattersArticles/downloads/SE0462.pdf).

To be sure you've got the information you need to apply Medicare's rules appropriately, here are some extra pointers to consider before you code.

Don't Fret Over Distinct ICD-9 Codes

The MLN Matters article states, "If a patient has a significant adverse reaction to drugs during a chemotherapy session and the physician intervenes, the physician can bill for a visit in addition to the chemotherapy administration services."

In addition, if the patient had already seen the physician on the same day and develops an adverse reaction during therapy, you may be entitled to a higher-level visit or prolonged services as the article also states, "The total time, resources and complexity of the physician's interaction with the patient may justify a higher level of a visit service" than what you would have billed had the adverse reaction not occurred. (Reference CPT guidance in order to determine the correct level and codes to use.)

Key point: CMS does not require a separate diagnosis for the E/M and admin services.

Support: Medicare Claims Processing Manual, chapter 12, section 30.6.7.D (www.cms.hhs.gov/Manuals/IOM/list.asp) states, "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 [Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service]. 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."