May 2012 Coding Tip (View More Coding Tips and News Alerts)
Billing Evaluation/Management Services on the Same Day as Drug Administration
By Ashley Miller, CPC
It is good practice for Medical Oncologists and Hematologists to provide frequent “face-to-face” services with their chemotherapy patients. Patients’ treatment schedules quite often require weekly, or even daily, visits to their physician’s office. In today’s busy world, each of those trips can be a burden to a patient already burdened with other medical, surgical, testing, and imaging appointments. Not wanting to add more strain on their often fragile patients, physicians regularly schedule an office visit (Evaluation and Management [E&M] service) on the same day a patient is coming into the office for treatment.
An E&M service is routinely bundled with most other services on the same day, including chemotherapy, and not billed unless it can be identified as a “significant, separately identifiable service,” (Center for Medicare and Medicaid Services Transmittal 2159, February 15, 2011). If it is a separate service, then a 25 modifier, identifying it as billable, may be appended to the E&M CPT (Current Procedural Terminology) code. So, how is an office visit determined to be a separate service, qualifying for an unbundling modifier?
The CPT Manual states, “A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported . . . [which] may be prompted by the symptom or condition for which the procedure and/or service was provided.” In other words, if during the visit with the patient the physician reviews new or additional information, such as lab or test results, or addresses the patient’s new or continuing symptoms or treatment side effects, this would be considered services “separately identifiable” from the same-day chemotherapy treatment. Billing for such an office visit would then be warranted, and the appropriate E&M level CPT code may be reported with a 25 modifier. However, modifier 25 shouldn’t be appended to 99211 (nurse’s visit) as this code doesn’t have any key components required to meet therefore; it cannot be considered a significant or separately identifiable service. As with any service, clear documentation in the patient’s chart must support the charge and the modifier. Important to note is an E&M service provided on the same day as another service does NOT require a different diagnosis.
The proper use of modifiers can prevent denials and increase overall revenue. Revenue Cycle, Inc.’s staff can provide education and guidance in appropriate billing practices that utilize the correct modifiers to ensure full reimbursement. If you would like more information regarding the consulting services provided by RCI, contact us at 512-583-2000.