Oncology & Hematology Coding Alert

Appropriate ICD-9 codes help prove your case to payers

If your oncologist performs and documents all the conditions for an evaluation and management service and provides a separate service, follow these three steps to learn when - and when not - to use modifier 25. Plus: We're offering a tool to help you win an appeal if a carrier denies your claim. 1. Identify the Right Time to Code Injection and E/M In some circumstances, your oncologist can bill for both an injection and an office visit, even though Medicare may have bundled these services in the past. 

Anytime the oncologist performs an E/M in addition to a procedure you're coding, such as a chemo injection, append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code if you need to tell your payer that the E/M is separate from the procedure, says Carolyn Davis, CMA, CPC, CCP,  CCS-P, CPHT, RMC, billing supervisor for Oncology Hematology West, and approved PMCC instructor for the AAPC, in her presentation "Using G Codes to Bolster Your Bottom Line."

Caution: Before you separate out the E/M with modifier 25, be sure the physician performed an exam that will satisfy coding and medical-necessity guidelines, says April Borgstedt, CPC, coding specialist and president of Working for You Consulting in Broken Arrow, Okla.

Medicare Transmittal 147 tells you that carriers pay for E/M services, other than CPT 99211(Office or other outpatient visit for the E/M of an established patient, that may not require the presence of a physician ...), provided on the same day as chemo administration or nonchemo drug infusion if:
  you append 25 (even though the underlying codes don't have global periods), and
  the E/M service meets the requirements found in Chapter 12, section 30.6.6 of the Medicare Claims Processing Manual.

You'll find this Medicare transmittal online at www.cms.hhs.gov/manuals/pm_trans/R147CP.pdf.

Heads-up: Coding guidelines and insurers' policies may not require that you use different diagnosis codes for the procedure and E/M when you append modifier 25, but doing so increases your chances of getting paid with some carriers, Borgstedt says.

Example: If the patient presents for chemotherapy, cite the malignancy as his primary diagnosis (such as, 163.x, Malignant neoplasm of pleura). If the oncologist performs an E/M above the 99211 level because the patient complains of another medical issue, such as nausea and vomiting (787.01, Nausea with vomiting), link this diagnosis code to the E/M. 

Special note: Even if insurers do require a separate condition or reason for the E/M service, make sure you don't artificially come up with diagnosis codes to support the separate E/M charge, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator [...]