Oncology & Hematology Coding Alert

But only if the oncologist provides a truly separate E/M

Adding modifier 25 to your 2006 injection coding toolbox may clear up one of your most frustrating problems. Here's how.

Medicare is supposed to pay for a separate office visit, except for a level-one office visit (99211), along with new injection code 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). But many coders report that Part B carriers are denying either an E/M code or 90772 when they code both on the same date.

Solution: Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code, says coder Ronda Scalise with Premier Medical Group in Clarksburg, W.V. Anytime she forgets to put modifier 25 on the office visit, the carrier has denied it, instead paying only for the -J- code for the drug and 90772 for administration.

The National Correct Coding Initiative manual says you can report -other office/outpatient evaluation and management CPT codes- along with 90772, but you must use modifier 25. And the physician must provide -a significant and separately identifiable E/M service,- the manual states in chapter 11, section 5.

Put Modifier 25 to Work for You

Example: The oncologist provides EPO for chronic anemia. Per your documentation, you report J0885 (Injection, epoetin alfa [for non-ESRD use], 1,000 units) for the EPO, 285.9 (Anemia, unspecified) for both the injection and drug, and 90772 for the injection. While at the appointment, the patient complains that he has developed nausea with vomiting (787.01, Nausea with vomiting), and the oncologist performs a level-two E/M (99212, Office or other outpatient visit ...). Remember to append modifier 25 to 99212.

Important: The separate E/M doesn't need a different diagnosis than the injection service, says consultant Debbie Farmer with Auditing for Compliance and Education in Joplin, Mo. But you do need to document that the physician did -significantly more than just providing the therapeutic injection services,- she says. You must show work above and beyond preparing the patient for an injection.

Tip: Make sure your documentation will pass OIG muster by reviewing its special report on modifier 25: http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf.