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EM visit billed with Chemo or Infustion Injections

Penelope Posted Wed 01st of February, 2012 20:59:18 PM

Do you have a link or reference guide that I can provide to our providers which clearly spells out an EM can only be reported with infusions & chemo when there is medical necessity. Our providers feel they're entitled to an EM reimbursement every time a patient is scheduled for these treatments without supporting medical necessity.
I don't know how else to convey to them that this is fraud.

I have two specialties, Renal and Hematology that won't change their codiing behavior and need some concrete guidelines to convince them.

Please help!!
Thanks you.

SuperCoder Answered Mon 13th of February, 2012 16:40:55 PM

Hello – This is certainly a tricky area. Here are some resources to consider:

Medicare Claims Processing Manual, chapter 12, section 30.6.7.D ( states, “when a medically necessary, significant and separately identifiable E/M service (which meets a higher complexity level than CPT code 99211) is performed, in addition to one of these drug administration services, the appropriate E/M CPT code should be reported with modifier 25 [Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service]. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required.”

For info on what’s required for reporting adverse reaction care, try this article:

There’s also this in the CCI Policy Manual (chapter 11,
7. The drug and chemotherapy administration CPT codes 96360-96375 and 96401-96425 have been valued to include the work and practice expenses of CPT code 99211 (evaluation and management service, office or other outpatient visit, established patient, level I). Although CPT code 99211 is not reportable with chemotherapy and non-chemotherapy drug/substance administration HCPCS/CPT codes, other non-facility based evaluation and management CPT codes (e.g., 99201-99205, 99212-99215) are separately reportable with modifier 25 if the physician provides a significant and separately identifiable E&M service. Since physicians should not report drug administration services in a facility setting, a facility based evaluation and management CPT code (e.g., 99281-99285) should not be reported by a physician with a drug administration CPT code unless the drug administration service is performed at a separate patient encounter in a non-facility setting on the same date of service. In such situations, the evaluation and management code should be reported with modifier 25. For purposes of this paragraph, the term “physician” refers to M.D.’s, D.O.’s, and other practitioners who bill Medicare claims processing contractors for services payable on the “Medicare Physician Fee Schedule.”

Deborah Marsh, JD, MA, CPC, CHONC
The Coding Institute

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