Oncology & Hematology Coding Alert

Many oncology coders mistakenly believe E/M services and chemotherapy services are bundled but it's time for you to learn the truth and to receive proper reimbursement for both services.

Not only can you be reimbursed when the chemotherapy services are provided incident-to, but many LMRPs substantiate the practice of reporting E/M services with chemotherapy to get the reimbursement you deserve, and we'll show you how to do just that.

Medicare recognizes the need for physicians continually to monitor and manage a patient's chemotherapy treatment, allowing them to be reimbursed for both E/M services and administration. The Medicare Carriers Manual states that "payment may be made for an evaluation and management service provided in conjunction with chemotherapy." You can bill for E/M services as long as the services are separately identifiable and are not related to the chemotherapy, says Dianne McQuarrie, CPC, insurance specialist, Central Georgia Hematology Oncology, in Macon, Ga. She explains that, often, a physician sees a patient to follow up on the status of his health, results of labs, outside consults, surgeries, or radiological services. On the same day, the patient will receive his intravenous chemotherapy treatment. In cases like this, you should code for the chemotherapy administration using 96408-96414. Don't forget to report the E/M services with codes from the series for established outpatient visit (99211-99215). Also, remember that 96412 is an add-on code and should be listed separately in addition to the code for the primary procedure.

The "nurse-only visit" (99211) is the most common E/M service related to chemotherapy administration. If nurses provide nursing evaluations or direct patient care, if it is properly documented, you will report 99211. Be careful not to bill for this service when the nurse only administers the chemotherapy and does not do extra services, such as checking vitals or giving other injections. Code 99211 is often misused, so do not report it when patients come in to pick up supplies or drugs, because there is no examination taking place. Medicare does not require you to append modifier -25 (Significant, separately identifiable E/M service by the same physician ...) with the E/M service codes.

Remember that 99211 is not the only code available when coding for chemo-related E/M services. Higher levels of E/M codes should be considered if the patient sees a physician or other midlevel provider. McQuarrie says that the level reported depends on whether the patient sees the physician. Then, you should code for the level of service he provides, taking into consideration the key components of an E/M visit: history, exam and medical decision-making. As long as they meet the documentation requirements for 99212-99215, Medicare will pay for the E/M services in addition to the chemotherapy. This documentation should support the notion that the E/M was separate from the administration and show that the physician had face-to-face contact with the patient. It should show what happened during the visit and the time period of the visit.                                                

Also, don't forget the time factor. If the doctor spends more than half of the visit counseling the patient or family, the amount of time can be used to determine the level of E/M service. It is useful to report different diagnosis codes for the higher-level E/M codes and the chemotherapy codes in order to substantiate the claim that the service was independent of chemotherapy.

"Chemotherapy administration and incident-to services are paid on the same day and allowed per Medicare as long as there is documentation of physician involvement in the patient's care," says Carolyn M. Davis, CPC, CCP, CCS-P, billing supervisor for Oncology Hematology West PC. In other words, if the nurse or other assistant performs services, such as looking at lab results, taking vitals, and taking an assessment and asks the physician to become involved, then you can charge an E/M service (usually 99211) as incident-to.                                      

This issue of incident-to has been a topic of discussion for quite some time. CMS has tried to clarify the issue on several occasions. Guidelines hold that incident-to can be administered by a nurse practitioner or physician assistant (PA), Davis says. The key to the incident-to enigma is that the physician must be in the office suite. If he is in the hospital making rounds or only in the building, then you cannot bill 99211 incident-to. Empire Medicare's LMRP reiterates this idea that "on days when the physician has no face-to-face contact with the patient and services are rendered by a staff member 'incident-to'the physician, CPT99211 should be reported." Carefully document all procedures when attempting to receive reimbursement for incident-to services.

Stay on the Straight and Narrow for Non-Medicare Payers

You need to be careful when reporting separate E/M services with chemotherapy for non-Medicare carriers. Sometimes, they will reject E/M service claims when they are provided on the same day as administration. The practice of reporting 99211 for visits that don't qualify as separate E/M services has increased scrutiny among non-Medicare carriers who sometimes reject this code.                                    

But don't lose hope. You should bill for E/M services when you can prove that the visit was separate from the chemotherapy administration. McQuarrie notes that most commercial carriers require that you append modifier -25 onto the E/M code. She finds that many payers, such as Blue Cross/Blue Shield, Principal, and Tri-Care, all want to see modifier -25 with the E/M code or they will bundle the service into the chemotherapy administration codes.                                                   

 For example, a patient arrives for chemotherapy administration and complains of a severe headache. The symptoms force the nurse to focus a portion of the visit on the complaint and seek the advice of the oncologist in the office. The physician advises the nurse on treatment, and the chemotherapy is administered as scheduled. You should report 99211-25 with a diagnosis code of 784.0 (Headache) for the visit and 96410 (Chemotherapy administration, intravenous; infusion technique, up to one hour) with a diagnosis code representing the patient's cancer.

Above all else, you should check with your carrier and request guidance regarding its coding preference.