Oncology & Hematology Coding Alert

Question: My oncologist and I disagree about whether we should bundle E/M services (99211-99215) and chemotherapy administration (96400-96549). I believe we can bill them separately, but he doesnt. Whos right?

Kansas Subscriber

 

Answer: You are correct, depending on the insurer and the circumstances of the treatment. Although Medicare reimburses oncologists for reporting both E/M services and chemotherapy administration separately, non-Medicare payers routinely reject E/M claims when the physician provides them on the same day as administration. And because E/M services are common preludes to chemotherapy treatment, distinguishing a chemotherapy-related visit from a separately identifiable service could be difficult. So you should bill a non-Medicare payer only when you can prove the office visit was separate from the chemotherapy treatment.
 
For example, during a nurse-only visit for chemotherapy administration for colon cancer (154.0 Malignant neoplasm of rectum, rectosigmoid junction, and anus; rectosigmoid junction), the patient complains of a severe headache (784.0). After examining the patient, the nurse seeks the oncologists advice. The nurse treats the headache, and the chemotherapy continues as scheduled. In this case, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99211 (Office or other outpatient visit ... established patient) and include 784.0 in your report to bolster your case that the nurse provided a separate service. Dont bill 99211 separately if the nurse administers routine care prior to the chemotherapy treatment, such as when he or she checks blood pressure, asks and answers questions, flushes or cleans ports and prepares the patient for administration. Also, you shouldnt report 99211 when a patient picks up supplies or drugs.