Oncology & Hematology Coding Alert

Question: Our provider recently diagnosed symptoms of nausea and headache in a patient who is being treated with chemotherapy. After evaluation of the patient’s condition, our physician decided to inject the patient with two intramuscular injections. Is it right to bill 99213-25, 96372x2 with modifier 59 along with the appropriate J codes? Do we have to report a separate E/M? 

Texas Subscriber

Answer: As described in  your question, you can bill both the E/M with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) and the therapeutic injection codes. However, documentation must support the situation you described showing the E/M service was significant and separately identifiable from the therapeutic injections. Submit code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem[s] and the patient’s and/or family’s needs. Usually, the presenting problem[s] are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family) for the E/M service. You can also submit two units of code 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) for the two injections. Don’t forget to also report the medications and specific quantities administered.

If billing for any significant, separately identifiable E/M service with modifier 25, make sure the documentation supports the key components (i.e. history, exam, and medical decision making) were done. Some providers will even separate documentation of the E/M service from the administration of the injections provided at the same encounter. Without sufficient documentation, you cannot bill a separate E/M code.

According to the E/M documentation guidelines, “an E/M service for an established visit requires two of three key components: history, examination, and decision-making. Documenting only the evaluation of a separate problem without documenting the management component (what was done about the problem) is incomplete and will result in a denial, with or without the Modifier 25.” And don’t forget, medical necessity must be the overarching criteria for E/M level selection (MCM 100-04, Chapter 12, Section 30).