Urology Coding Alert

Still billing 96400 with 99211? Not anymore, Medicare says

If you're confused by recent CMS transmittals regarding 96400 and 99211, you're not the only one. We've got the skinny on when you can - and can't - report E/M services with chemotherapy administration.

In a transmittal dated April 23 (implemented May 24), Medicare revised its payment policy for chemotherapy administration and nonchemotherapy drug infusion services. It established work relative value units (RVUs) for several CPT Codes, including 96400 (Chemotherapy administration, subcutaneous or intramuscular, with or without local anesthesia). The RVUs are equal to the RVUs for 99211, a level-one established patient office visit.

The catch: You can't report 96400 with 99211 anymore. "For services furnished on or after Jan. 1, 2004," the transmittal says, "carriers shall not allow CPT code 99211 (with or without modifier -25) to be billed or paid on the same day as a chemotherapy administration service or nonchemotherapy drug infusion service." It's also now an Ncci Edits , with a status indicator of "0," forming an unbreakable bundle. In other words, says Doris Kozdron, CPC, coding specialist for Huron Valley Urology Associates in Ypsilanti, Mich., if you report 99211 on the same day as a drug injection code, Medicare will pay only for 99211.

However: Kozdron notes that in 2004 the marked increase in Medicare payments for 96400 (the addition of a work value and a 32 percent transitional increase) will more than adequately compensate for the inability to bill  99211 in addition to 96400. In 2004 the payment for 96400 alone is substantially more than the payments for 99211 and 96400 made in combination in 2003.

"Part of the reason that they increased that fee [for 96400] was that they decreased payment on a lot of the chemo drugs that we use," Kozdron says. "For example, they decreased the allowable for Lupron to 81 percent of the AWP [average wholesale price]. So they are now allowing more for 96400."

You can still report E/M services above the 99211 level, if you append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). If the urologist is providing E/M services that justify a higher level - such as assessing whether to administer the next dose and making sure there are no contraindications for the medicine - it does warrant a charge and a payment, says Dan Rogers, practice administrator for Gulf South Urology in Biloxi, Miss.

Example: A prostate cancer patient comes in for a Lupron injection. The urologist reviews his systems, checks his prostate and goes over the PSA results with the patient, and discusses concerns and side effects. Report 96400 and 99212-25 (Office or other outpatient visit for the evaluation and management of an established patient; significant, separately identifiable E/M service) along with HCPCS Level II code J9217 (Leuprolide acetate [for depot suspension], 7.5 mg) for the supply of Lupron.

Important: When you do separately report E/Ms and 96400, be sure to link all the codes to the same ICD-9 diagnosis code - for example, 185 (Malignant neoplasm of prostate).

To download a copy of the transmittal from CMS, visit www.cms.hhs.gov/manuals/pm_trans/R147CP.pdf.