Oncology & Hematology Coding Alert

Question: Insurers often deny our practice's claims when we attach modifier -25 to a code. Do you have any tips on how to avoid denials with this modifier?

New York Subscriber

Answer: Oncology coders can avoid denials and lost reimbursement if they know how to appropriately report modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Review the following quick tips to help avoid denials, and check with your carrier for its specific modifier -25 guidelines.
 
1. Append modifier -25 only to E/M services. Do not use the modifier on any procedure codes. You should use modifier -25 with an E/M service (for example, 99211, Office or other outpatient visit ... established patient ...) that the oncologist performs on the same day as another procedure, such as chemotherapy administration (96400, Chemotherapy administration, subcutaneous or intramuscular, with or without local anesthesia).
 
2. Do not append modifier -25 to E/M codes when the only other codes you use for that claim represent ancillary services, such as x-rays (71010, Radiologic examination, chest; single view, frontal). Also, most insurers prohibit practices from using modifier -25 with an E/M service that leads to a surgical procedure. Often you should attach modifier -57 (Decision for surgery) when an office visit leads to surgery. Make sure to check with your insurer for additional restrictions and guidelines.
 
3. Include separate documentation for both your E/M and procedure codes. To medically justify reporting both an E/M code and a procedure code, you must supply separate documentation for each service, coding experts say.
 
For instance, before a scheduled bone marrow biopsy (38221, Bone marrow; biopsy, needle or trocar), your physician examines the patient, who complains of nausea and vomiting (787.01) unrelated to the biopsy. In that case, if your physician provides additional treatment for the sickness, you could report an E/M service (9921x-25, Office or other outpatient visit ...; significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) in addition to the biopsy code (38221).
 
But to ensure payment, make sure the oncologist separately documents the E/M service and biopsy and doesn't combine documentation. For example, you may want to link separate ICD-9 codes to 9921x-25 and 38221.