Oncology & Hematology Coding Alert

Plus: Bone marrow biopsy codes are potential OIG targets

After a disappointing survey of claims reporting modifiers 25 and 59, the Office of Inspector General (OIG) is encouraging Part B carriers and Recovery Audit Contractors to keep an eye out for modifier misuse. Prepare to see an increase in prepayment and postpayment audits for both modifiers.

Abide by Every 59 Guideline

Keep yourself out of trouble by watching your claims for these modifier 59 (Distinct procedural service) red flags.

1. Confirm that the procedures you claim are distinct and weren't performed at the same session, same anatomical site, and/or through the same incision.

Examples: The OIG's review revealed that providers used modifier 59 improperly to override the National Correct Coding Initiative (NCCI) edit that bundles 38220 (Bone marrow; aspiration only) into 38221 (Bone marrow; biopsy, needle or trocar). Lesson: Only report 38221, 38220-59 when the aspiration and biopsy are performed at separate (noncontiguous) anatomic sites or at separate patient encounters.

Chemotherapy and other IV infusion services seemed to be frequent culprits, as well. In 2005, you had to use modifier 59 anytime you coded an additional IV push, subcutaneous injection, or E/M visit with any infusion, says Andrea Peters, infusion billing manager for Texas Hematology/Oncology in Dallas. The 2006 sequential infusion/injection codes (such as 90767 and 90775) should reduce the need to report 59 with these services.

Helpful: Though using distinct ICD-9 codes for each of the separate procedures isn't required, you may be more likely to convince payers with distinct diagnoses, says Margie Vaught, a coding consult in Ellensburg, Wa. But only report the diagnosis documented by your physician.
 
2. Make sure your documentation supports coding for both services.
 
3. Append modifier 59 to the component code, rather than the primary service code or both codes.

Example: NCCI bundles 36000 (Introduction of needle or intracatheter, vein) into 77295 (Therapeutic radiology simulation-aided field setting; 3-dimensional). You perform both on the same day separately. Report 77295, 36000-59.

4. Be certain you-re reporting the correct code.

This may sound obvious, but 7 percent of the incorrect modifier 59 claims the OIG audited reported the wrong code.

Resource: CMS posted an article on modifier 59 on its site. Check it out under -Downloads- at www.cms.hhs.gov/NationalCorrectCodInitEd/01_overview.asp.

Prevent Modifier 25 Mishaps

In its survey of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) claims, the OIG pointed out three main problems. Here's how to avoid them.

1. Be certain your claim includes E/M services that are significant and separately identifiable.

The E/M should be above and beyond the usual preoperative and postoperative care associated with the procedure.

When you-re applying modifier 25, you should remember the maxim -If you don't have a HEM, you can't bill an E/M,- says Laureen Jandroep, director and senior instructor for CRN Institute in Absecon, N.J. Here, -HEM- stands for -history, exam and medical decision-making.- All procedures include a mini-E/M visit related to the procedures, but a separate E/M should include its own HEM, Jandroep says.

Example: A patient presents for chemotherapy, but a reaction to the medication requires the oncologist to provide a level-two E/M. Report the appropriate chemo code (such as 96413, Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) and append modifier 25 to E/M code 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making).

2. Focus on compiling complete documentation of both the procedure and the separate E/M. 

-When you put the 25 modifier on, you-re telling the payer, -I have documentation to back it up,- - Jandroep says. One simple way to audit-proof your documentation is to use a basic line to separate the procedure from the E/M, she adds.

Another option: You should consider developing forms that separate E/M and procedural notes.

3. Don't append modifier 25 if an E/M is the only service your oncologist provides the patient that day.