Wiki Billing an office visit and chemo same dos

[bmay]

I work at a drs office and we peform chemotherapy in the office and have the following question:

The patient comes in for an office visit and chemotherapy cycle 2 day 1. The dr peforms ROS, does an exam, reviews labs, does an assessment and notes no changes to pts dx or new problems and does not change the treatment plan and sends the patient to the treatment room for chemotherapy. Is this office visit billable with a -25 modifier? If you could explain why you believe it is or isn't a billable service that would be very helpful.

Thank you.

 

[OCD_coder]

Chemotherapy infusion codes are exempt from the modifier 25 rules per NCCI Coding Manual Guidelines, see Chapter 1 on the CMS website. The infusions have an XXX global status indicator and do NOT have an E&M included within those services like other minor procedures do. The provider must evaluate the patient to be sure they are healthy enough to recieve chemotherapy, labs are reviewed for these visits typically looking for any type of anemia or residual effects on the body systems from the chemotherapy. So the E&M is billable and should have a modifier 25 appended to separate it from the infusion codes on the same day.

Some auditors will disagree, but I have never had a carrier deny this rationale in over 12 years.

 

[bmay]

My question now is modifier 25 states you need a "significate, separately identifiable e/m service" in order to be able to use it.

So are you saying dont need to a have separate reason to append the -25 modifier to the office visit such a new problem or worsening conditon, just performing the office visit qualifies for the use of the -25 modifier?

Thank you.