Oncology & Hematology Coding Alert

Question: Did the January Correct Coding Initiative (CCI) release delete the edits bundling clinical treatment plans and simulations into new and established patient visits?

Texas Subscriber

Answer: CCI version 16.0 does not delete edits bundling new and established patient E/M visits into clinical treatment plans (77261-77263) and simulations (77280-77295), but it does change the modifier indicator.

Before Jan. 1, the modifier indicator for these edits was "0," meaning that you could not override the edit. But the Jan. 1 release changed the modifier indicator to "1," which means you may override the edit using a modifier.

How this helps: You previously could report a consult E/M code on the same date as treatment plans and simulations, but CMS no longer covers consult codes, effective Jan. 1. The modifier indicator change allows you to report an appropriate new or established patient E/M in those instances where you used to report a consult to Medicare.

Example: The oncologist sees a new Medicare patient and performs a service you previously would have coded as a consult. Because Medicare no longer accepts consult codes, you choose the appropriate new patient office visit code (such as 99205, Office or other outpatient visit ...).

The oncologist also documents simple clinical treatment planning on that date of service. You report 77261 (Therapeutic radiology treatment planning; simple). Then you append modifier 25 (Significant, separately identifiable evaluation and management service on the same day of a procedure or other service) to the E/M code to indicate it was a separately identifiable service.

Resource: You can download the most recent CCI edits at www.cms.hhs.gov/NationalCorrectCodInitEd/.