Oncology & Hematology Coding Alert

Question: We have a small practice in a designated health professional shortage area (HPSA). Because our physician on regular duty fell ill, we got an HSPA physician to substitute for his services as a locum physician. That morning, the locum physician performed chemotherapy for the patient. The patient reports to the practice again that evening, and an HSPA physician performed a level-three E/M service. We have a signed advance beneficiary notice (ABN) on file for the patient. Can you provide guidance for what modifiers we can append for multiple services?

Illinois Subscriber

Answer: You’re going to need several modifiers for this E/M service, including modifier 99 (Multiple modifiers). You will also need to check if your payer recognizes it. Coders should use modifier 99 when the number of modifiers for a claim line are more than the fields’ available on the claim form.

Coding: Report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity…) for the E/M with modifier Q6 (Service furnished by a locum tenens physician) for the substitution by another physician. Modifier Q6 implies that the physician who performed the E/M is “filling in” for the ill physician on a locum tenens basis. You also need to attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code because the patient received chemotherapy earlier that day from the same physician.

Additionally, you need to append modifier AQ (Physician providing a service in an unlisted health professional shortage area [HPSA]) because the physician is providing the service in a HPSA. Lastly, because your office has an ABN signed by the patient on file, you need to include GA (Waiver of liability statement issued as required by payer policy, individual case) as well.

You will want to report your modifiers in order of payment and significance. The order of these would be the 25, AQ, Q6, and GA. All of these are important.  You want to put them in the correct order to be properly reimbursed. The 25 shows payment should be made separate and apart from the infusion procedures on the same day and modifier AQ adds money to your service, the Q6 is an important informational modifier.  It indicates a locum tenens physician is providing certain services on behalf of the treating physician under a temporary arrangement. Lastly, the GA is also information around payment and can be added last.

Do this: In this case, there are more modifiers than you could fit on a standard claim form. You may put modifier 99 in box 24D on the same line as the service and list the other modifiers in box 19. If you have fewer than four modifiers, modifier 99 would not be necessary.