Oncology & Hematology Coding Alert

Question: I am a facility coder, but I see both profee and facility codes on the bill when I work on it. My trainer has told me to add modifier 25 to a physician evaluation and management (E/M) service when a patient has both chemotherapy and a separate E/M on the same day. Clearly, modifier 25 would be applied when there is a facility E/M on the same day as chemo administration, but if a profee provider administers the E/M but not the chemo, I don’t think modifier 25 is necessary. So, which one of us is right?

AAPC Forum Participant

Answer: In your situation, as the facility is billing the chemo, and a physician is evaluating the patient during the course of the drug administration without using facility resources, then the facility is not billing for the provider’s E/M and there is no need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code.

In other words, the pro-fee service would not bundle with the infusion, since the infusion administration is part of the facility resources, and the pro-fee visit is a standalone service billed independent of facility resource utilization.

However, for facility (UB-04) billing where the physician is seeing the patient in a provider-based department of the facility, and the facility is billing a clinic charge for that visit (for example, G0463 [Hospital outpatient clinic visit for assessment and management of a patient]), then you’ll need modifier 25 on the facility claim when also billing chemotherapy. In this case, you would need to support the modifier with documentation showing that the service goes above and beyond the usual pre- and post-procedural work included in the chemotherapy service.

So, if the physician is performing a full “office visit” type of service involving the clinic staff prior to or after chemo, then the modifier may be valid. But if the physician is simply evaluating the patient during the course of the drug administration and there is no facility resource involved in that E/M service, then the facility shouldn’t be billing for it.

NCCI alert: The National Correct Coding Initiative (NCCI) policy manual states that the chemotherapy and highly complex drug administration codes (96360-+96375 and 96401-96425) “have been valued to include the work and practice expenses” of 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional). So you cannot bill 99211-25 with any chemo administration under any circumstances.

But “other nonfacility-based E/M CPT® codes (e.g., 99202-99205, 99212-99215) are separately reportable with modifier 25 if the physician provides a significant and separately identifiable E/M service.” Additionally, facility-based E/M codes “(e.g., 99281-99285) shall not be reported by a provider/supplier with a drug administration CPT® code unless the drug administration service is performed at a separate patient encounter in a nonfacility setting on the same date of service” according to the NCCI Policy Manual (www.cms.gov/files/document/ chapter11cptcodes90000-99999final11.pdf).