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Oncology & Hematology Coding Alert

Reader Question:

E/M Reimbursement Possible With Some Surgeries

Published on Mon Nov 15, 2004

Question: A new patient with anal cancer reported to the office for a diagnostic sigmoidoscopy. Operative notes indicate that staff provided a level-four evaluation and management service prior to sigmoidoscopy, but can we code for both services?

Georgia Subscriber
 
Answer: If you prove medical necessity for a level-four E/M service and a sigmoidoscopy - and provide enough documentation to show that the services were separate - you should receive payment. Many oncology practices provide separate E/M services when performing minor surgeries, but not every office reports two codes when they can.

On your claim, you should:

  • report 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the sigmoidoscopy

  • report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity) for the E/M service

  • attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99204 to show that the E/M service was not part of the sigmoidoscopy

  • attach ICD-9 code 154.3 (Malignant neoplasm of rectum, rectosigmoid junction, and anus; anus, unspecified) to 99204 and 45330.

    Heads-up: In addition to the above codes, make sure you include documentation that proves the distinct and separate nature of the sigmoidoscopy and the E/M service. In general, this means that the surgical procedure will have documentation that is separately identified from the patient visit.

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