Oncology & Hematology Coding Alert

Question: We have an oncologist in our practice who insists on adding an office/outpatient evaluation and management (E/M) code for every procedure for a patient that already has an established plan of care. The provider states that the patient’s care plan changes at every encounter, even if they are coming in for a procedure to treat a condition they have had for some time, as the condition is always changing.

However, when I look at the documentation, I see nothing has changed since the last encounter, and no new problems are being addressed to justify the E/M. How do I communicate effectively to the oncologist that only the procedure can be billed in these circumstances?

AAPC Forum Participant

Answer: In order to legitimately bill an established patient E/M using 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient …) along with any procedure, you must append 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. As the descriptor language indicates, this E/M must be significant and separately identifiable from the problem the provider is addressing with the procedure.

However, you say that nothing in the notes supports a separate or significantly identifiable E/M. Therefore, you cannot bill for the E/M. Remind your oncologist all procedures have an inherent pre- and post-procedure visit component. A separate E/M requires additional evaluation and medical management above and beyond the pre- and postoperative care associated with the procedure.

For many encounters in oncology, patients are seen for ongoing care of an existing complaint. Unless there is a new complaint, or a major modification to an existing care plan that takes a new complaint into account, you should only bill for the procedure. Any minor E/M related to an existing condition would be covered as a part of the service described by the appropriate procedure code.