Get Paid for Same-date E/M Service and Chemo Administration by Non-physician Provider
Published on Mon Nov 01, 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 [...]
