Oncology & Hematology Coding Alert

Question: Is it appropriate to code for an evaluation and management (E/M) and intrathecal chemotherapy during the same hospital visit?

California Subscriber

Answer: Codes 96400-96549 (chemotherapy administration) are independent of the patients visit. If a significant and separately identifiable E/M service is performed, it should be reported in addition to modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Either may occur independently or sequentially on the same day of service. Medicare will allow billing 96450 (intrathecal chemotherapy) by a physician in the hospital. A private physician not employed by the hospital can bill for both 96450 and an E/M service (99221-99223). Code 96450 covers a physicians supply cost and overhead incurred when administrating chemotherapy, which would not be the case in the hospital setting. When a private doctor performs an inpatient E/M service, he or she should bill for the service without 96450. Some private insurance companies may allow both with modifier -26 (professional component) appended to 96450 when performed in a hospital.

Answered by Felecia Bernstein, CPC, EMT, a coding and reimbursement specialist and president of the Monmouth chapter of the American Academy of Professional Coders, Monmouth, N.J.