Oncology & Hematology Coding Alert

Question: I'm confused by all the coding changes in oncology this year. Is it true that Medicare no longer allows us to report chemotherapy codes in addition to an E/M code, even with modifier -25?

Texas Subscriber

Answer: In Transmittal 147, issued April 24, 2004, the Centers for Medicare & Medicaid Services explains that it has established work relative value units (RVUs) for chemotherapy administration codes 96400, 96408-96425, 96520 and 96530, plus nonchemotherapy drug infusion services 90780-90781 and drug injection codes 90782-90788. These codes previously lacked work RVUs.

Each of these codes will have work RVUs equal to those for a level-one E/M visit for an established patient (99211). But CMS won't pay for 99211 on the same day as a chemo administration code or nonchemo drug infusion service.

Examples: If your oncologist billed 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) and 99211 (Office or other outpatient visit for the E/M of an established patient ...), Medicare would pay only for 99211. But if the physician billed 96400 (Chemotherapy administration, subcutaneous or intramuscular, with or without local anesthesia) in addition to 99211, Medicare may pay only for 96400.

If you assign an E/M code higher than 99211, such as 99212, you should use modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). For instance, if your documentation was appropriate, you could report 99212-25 to represent the separate E/M service.