Published in Oncology & Hematology Coding Alert, November 1999
When a patient presents for administration of chemotherapy, a physician is not usually scheduled to see him or her. But sometimes such attention is called for. However, many oncology practices report it can be challenging to obtain adequate reimbursement for an evaluation and management (E/M) service (99212-99215) provided on the same date as chemotherapy administration (96400-96549). What is optimal coding for this situation?
Ron Nelson, PA-C, advisor to the AMA CPT Healthcare Professionals Advisory Committee for the American Academy of Physician Assistants, first provides this example of when you would not code and bill an E/M service: A patient who is on a multi-drug chemotherapy regime comes in for periodic infusion and says, My mouth is really sore. The nurse examines the patients mouth and says, Youve got severe stomatitis. There is a protocol in place to cover this situation; the oncologist has specified that if someone has stomatitis (528.0), give them a particular prescription. The patient would get that prescription and the scheduled chemotherapy. The office would bill for the injection or infusion and the medication, and thats all. Billing for this visit would include (J9000-J9999) for chemotherapy medications, plus codes for any supportive drugs used, such as ondansetron (J2405), filgrastim (G-CSF) (J1441), and normal saline (J7030) for hydration. But since the physician or mid-level provider did not see the patient, no E/M code can be billed.
How to Bill Correctly for Incident-to Services
Nelson now considers when an E/M service can be billed: In the absence of a protocol for handling the new stomatitis, the nurse would ask the oncologist, physician assistant (PA) or nurse practitioner (NP) to see the patient, he explains. That individual would examine the patient and make a recommendation about treatment. In the example case above, if the oncologist, PA or NP saw the patient, you clearly would have met the criteria for an E/M service code: a chief complaint, history, physical findings, and a diagnosis consistent with a medically necessary visit. Thats a billable E/M code relative to a problem, and can be billed in addition to the chemotherapy treatment, with an E/M code (99212-99215) appended with a modifier -25 (significant, separately identifiable evaluation and management service performed on the same day).
Nelson emphasizes, Medicare will reimburse for an E/M service and chemotherapy administration (96400-96549) on the same date only if there is a separate identifiable evaluation service by the oncologist or someone who could substitute for a physician, such as a PA, NP or a clinical nurse specialist (CNS). But in such cases, the administration of chemotherapy (96400-96549) is considered as incident to the physicians initial visit and evaluation of the patient. Thus, the service is billed under the physician identification number (PIN) as if he or she had actually performed the service.
According to Medicare, a medical service qualifies as incident to if the services or supplies furnished are an integral, although incidental part of the physicians personal, professional services in the course of diagnosis or treatment of an injury or illness. It also stipulates that an incident to service must be:
1. commonly rendered without charge or included in the physicians bill;
2. of a type commonly furnished in the physicians office or clinic;
3. furnished under the physicians direct, personal supervision; and
4. furnished by the physician or an individual who qualifies as an employee of the physician (a PA, NP,
Note: Incident to codes do not apply in the inpatient setting.
Determining the Correct Level of E/M Service
To bill E/M services correctly the appropriate code level must be properly attained.
1. 99211: Sometimes called a nurse visit, 99211 can be a valuable code when the physician or other mid-level provider (NP, PA, etc.) does not need to see the patient, but an E/M service is performed. It is the lowest level office visit for an established patient, and the only E/M service code that doesnt require the presence of a physician or mid-level provider. (See Nurse-only Visits on page 3.)
2. 99212-99213: The example of the patient with stomatitis earlier in this article, where a physician must see the patient, would be coded as an established patient outpatient visit (99212 or 99213). A 99212 visit must include two of three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making, and typically involves 10 minutes of face-to-face physician time with the patient. A 99213 visit requires two of three key components: an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity, and typically involves 15 minutes of face-to-face physician time with the patient.
3. 99214-99215: Nelson continues, If the provider got into other issuesfor example, the patient is diabeticis the diabetes related to the chemotherapy? You move through the matrix of complexity and decision-making and problems that could advance it up the ladder to a more complex and complicated code (99214-99215). But the point is: Its more than just giving the chemotherapy or the previous diagnosis of cancer. Its now a separate, identifiable billable service.
The same principle would apply in complicated casesfor example, patients with advanced disease who have been on chemotherapy for a long time and are having multiple side effects, and/or who are no longer responding to the chemotherapy. The oncologist may need to evaluate the patient and discuss with him or her whether to continue the chemotherapy. This kind of outpatient visit would probably be coded as a 99214 or 99215. A 99214 visit requires two of three key components: a detailed history; a detailed examination, and medical decision-making of moderate complexity, and typically involves 25 minutes of face-to-face time between physician and patient. A 99215 visit requires two of three key components: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity, and typically involves 40 minutes of face-to-face time between physician and patient. Again, these examples would fit the criteria for a separately identifiable E/M service at the time of a procedure and would be billed by adding the -25 modifier to the appropriate E/M service code.
Using Modifier -25 Correctly
This modifier is supposed to be CPTs built-in mechanism for ensuring that you get paid for additional services being performed that are outside the normal scope of what is being billed (i.e., an E/M service as well as chemotherapy administration).
Medicare generally accepts the use of modifier -25, and commercial carriers should, too. And if denials occur, you should refer your carrier to the CPT passage: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patients condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.
MD Cant Bill for Chemo Administration
Oncologists normally dont administer chemotherapy; they delegate it to someone on their staff. If an oncologist sees a patient, evaluates him or her, diagnoses small cell tumor of the lung, and recommends a chemotherapy regime of three times a week plus radiation therapy, thats an E/M service, an established patient visit (99213-99215), Nelson says. But when the patient later comes in for the initial dose of chemotherapy, if the oncologist decides to administer the chemotherapy himself, he cant bill an E/M service just because hes a doctor. In other words, the codes need to reflect the service provided (in the case of chemotherapy administration, 96400-96549) rather than the credentials of the provider.
One E/M reimbursement opportunity related to chemotherapy administration that is sometimes overlooked is the nurse-only visit (99211). Before administering chemotherapy, the nurse or other provider often does a mini-evaluation, assesses and records the patients vital signs, and reviews lab work. The documentation must show the active involvement of the physician, PA or CNS in this process, even though he or she didnt see the patient.
As Laurie Lamar, RRA, CCS, CTR, CCS-P, explains, The documentation could be in the physicians progress notes, the nurses notes, the flow sheet or other appropriate record. For example: Dr. X reviewed counts and decided to continue chemotherapy. Or discussed patients nausea w/Dr. X. Nurse-only visits are an important service to chemotherapy patients and deserve to be reimbursed.
According to Lamar, reimbursement specialist for the American Society for Clinical Oncology (ASCO), private insurers are more likely than Medicare to deny payment for same-date E/M service and chemotherapy administration. Private insurers are not bound by CPT. Some insurers, though, may be swayed by a letter presenting Medicare regulations. Sometimes the insurer wants a modifier added.