Oncology & Hematology Coding Alert

Answer: Coding for a procedure on the same day of an exam depends on the circumstances. Medicare and other carriers assume that vital signs, weight, asking the patient how he or she is doing, obtaining consent and postprocedure monitoring are all part of the procedure.

When a patient is scheduled for a bone marrow biopsy, 85102 (bone marrow biopsy, needle or trocar), or a phlebotomy, 99195 (phlebotomy, therapeutic [separate procedure]), and either of those procedures is performed with the assessments listed above, it is appropriate to bill for the procedure only. In situations in which the patient is scheduled for a visit, and after a thorough history and exam, the physician decides to perform a procedure such as a bone marrow biopsy, the evaluation and management (E/M) code and procedure should be billed separately.

It is important to attach modifier -57 (decision for surgery) to the appropriate E/M code. This modifier is used when an E/M service results in the initial decision to perform the surgery or procedure. It would also be appropriate to bill both the E/M code and the procedure when a patient is scheduled for the treatment but during the time surrounding it a problem is identified and a full evaluation needs to be done.

For example: A patient presents for a bone marrow biopsy. While performing routine preprocedure care it is learned the patient has new onset bleeding. The physician does a complete history, exam and lab tests for this complaint. In this case, modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) would be appended to the E/M code to indicate that on the day the procedure or service was performed, the patients condition required a significant, separately identifiable service beyond the other service or usual preoperative and postoperative care.