Part B Insider (Multispecialty) Coding Alert

Documentation Is the Key

If a patient comes in for routine chemotherapy and doesn't see the doctor, can you still bill 99211 for incident-to services provided by a nurse or nonphysician practitioner?
 
Many consultants say no, unless the nurse or NPP does more work than simply making sure the patient is fit for chemo and preparing him or her. "My answer is no, you don't get the E/M separately," says Mike Misko, certified coder with Cavanaugh Michaels in Mechanicsburg, Pa. He says you'd have to justify using modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) with 99211 (Office or other outpatient visit for the E/M of an established patient, that may not require the presence of a physician) to prove that the nurse or NPP did extra work.
 
Even if the doctor sees the patient, Misko doesn't recommend billing for extra services unless the patient's circumstances change. The RVU for chemo includes physician work, practice expense and malpractice expense, he says. With chemo, "there's a script already written" including a basic history and checking for red flags.  
 
But consultant Quinten Buechner with ProActive Consultants in Cumberland, Wis., says this conventional wisdom is wrong. The Medicare Carriers Manual specifically states in section 15400B that on days when the patient receives chemotherapy but the physician has no face-to-face contact, the physician may report incident-to services as long as the physician was on-site and has documented active involvement in the patient's care.
 
Since the physician has prescribed chemotherapy, he's obviously involved in the patient's care, Buechner says. "It's not too terribly hard to get some E/M services" with chemotherapy, he adds. "You have to document your management and or evaluation of the patient," and this can include checking the patient's blood level. CMS will cover this because oncologists have successfully argued that chemotherapy isn't just like setting up an IV in the hospital and leaving the patient alone. "In chemo, that administering nurse is usually right there, and they are checking and they are doing E/M," Buechner says.
 
To document the need for this service, the patient's chart should show that the nurse wrote down the patient's stats, but also what the patient said about her condition and how she feels.