Oncology & Hematology Coding Alert

Question: We recently received a denial for 90772 from Medicare when we reported it with an office visit. Should we be doing something differently?


Michigan Subscriber
Answer: The solution is properly applying modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Example: The oncologist provides an E/M service that merits 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) and administers an injection (90772, Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular).

Append 25 to the E/M visit.

Note: If the E/M only merits 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician ...), you shouldn't report it with the injection to Medicare. (Medicare Claims Processing Manual Chapter 12, Section 30.5-30.6, www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.)