Oncology & Hematology Coding Alert

On Jan. 26, 2001, HCFA temporarily suspended version 6.3 of the National Correct Coding Initiative (CCI) edits that bundled 66 evaluation and management (E/M) services to more than 800 procedural codes, including chemotherapy administration (96400-96549).

In the past, Medicare has allowed E/M services and chemotherapy administration to be billed separately, recognizing the importance of managing patients chemotherapy treatment. But the edits took many oncology practice coders by surprise after they began noticing claim denials for E/M services previously paid separately, says Nanci Giacomozzi, office manager for P.K Administrative Services in Lakewood, Colo.

The most noticeable denials were the E/M services billed separately to chemotherapy administration, including 99211 (office or other outpatient visit).

Claims denied under the 6.3 edits should be resubmitted for adjustment with modifier -25 (significant, separate service by same physician on same day of procedure or other service) appended to the E/M service if it meets the separate and significant criteria. In deciding which claims may qualify, physicians and coders should look to the explanation of medical benefits on the insurance form. It will indicate that the claim was denied or reduced because:

1. The service was not significant or separately identifiable; or
2. Payment was included in another service received on the same day.

But, Giacomozzi advises oncology practices to check with their local Medicare carriers to determine what action should be taken. For example, Noridian Mutual Insurance Co., the Medicare carrier in Colorado, has already begun paying past denied claims without providers having to resubmit. Instead, the payer has reviewed claims that were returned from their office with the notation service not paid separately.