Oncology & Hematology Coding Alert

Question: Sometimes the oncologist/hematologistsees a patient for the first time; performs an E/M complete with history, exam, and medical decision making; and then decides to perform an unplanned bone marrow biopsy that same visit. May we report both?

California Subscriber

Answer: You should be able to report both for two reasons:

1. Documentation includes a history, exam, and medical decision making (HEM) separate from the biopsy.

2.The bone marrow biopsy was not the original or preplanned reason for the visit.

You should report the biopsy with 38221 (Bone marrow; biopsy, needle, or trocar) and choose the appropriate E/M code based on the documentation. Be sure to 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 the E/M code to indicate the separate nature of the service.

Helpful hint: CPT's Appendix A explains a significant and separately identifiable service "is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported."

Experts recommend asking yourself three questions when deciding if your case meets the criteria:

1. Could the complaint or problem stand alone as a billable service?

2. Do you have a different diagnosis for the portion of the visit unrelated to the initial service? (CPT explicitly states separate diagnoses aren't a requirement, but they can be a helpful clue, experts note.)

3. Did your physician perform extra work that went above and beyond the typical pre- or postoperative work associated with the procedure code?

If you can answer "yes" to any of those questions, you're one step closer to reporting modifier 25 correctly.