Oncology & Hematology Coding Alert

Deciding which codes and modifiers to report is a good start, but unless you know where to fill in the digits on your claim form, you-re still doomed to denials. Here's a step-by-step guide to properly reporting a modifier 25 claim to Medicare.

Scenario: A female patient with invasive breast cancer whose tumor is hormone-receptor negative presents for chemotherapy. Your facility does not bear the cost of the drugs. The oncologist performs a level-three E/M for this established patient because she complains of fatigue.

When a physician provides a separately identifiable and significant E/M service, you can charge for both the E/M and the injection/infusion/hydration codes, says Kevin Arnold, CPC, a coding instructor with Health Information Services Outpatient Coding in Danbury, Conn. This holds true for chemotherapy administration codes.

But to get E/M payment, you-ll need a hand from modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), says Michael Granovsky, MD, CPC, FACEP, vice president of MRSI, a billing company in Stoneham, Mass.

In this case, the CPT codes and modifiers you should use include:

• 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for the infusion
• 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) for the E/M service
• modifier 25 to show that the E/M service was significant and separate from the chemotherapy administration.

On the CMS-1500 form, you should enter:

1. The CPT codes in box 24-D under -CPT/HCPCS.- Because the chemotherapy administration is the primary service and the E/M service was secondary, list 96413 on line 1 and 99213 on line 2.

2. Modifier 25 in box 24-D under -Modifier- and on the same line as 99213.

Resource: Read the OIG report on modifier 25, and its misuse, online at http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf.