Oncology & Hematology Coding Alert

Question: I bill for an outpatient service department at a local hospital, and when patients come in for chemotherapy, we bill 96413. The oncologist is asking to be reimbursed for the professional fee for the service whenever one of their patients comes in, saying they should be paid for their time supervising the chemo in case of patient reaction. However, the patients are only there for their treatment and have not made an appointment with the oncologist. My question is: should we get both the technical and professional fees for the 96413 service, or do we split the charges with the oncologist?

AAPC Forum Participant

Answer: In this case, only the facility should bill 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug). Even though the services are being rendered pursuant to the physician’s order, the facility staff is performing the services and bearing all the costs of the medication(s) and related supplies. Consequently, there is nothing for the physician to be charging for, as the service is using all facility resources.

Remember: As stated in CPT^®, services within the 96360-96425 and 96521-96523 code ranges are not intended for physicians in the facility setting.

The oncologist cannot charge an evaluation and management (E/M) service in this case either, as this is a scheduled chemo service. The only way the oncologist could receive the professional component reimbursement for 96413 is if the chemo service is delivered in their own office, the oncologist/ practice is bearing all the costs to do so, and the oncologist is onsite to supervise the services.

Only when the provider performs a separately identifiable E/M service in addition to the infusion and injection service can you bill an E/M. In addition, 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) must be appended to the E/M service, and documentation must support the modifier assignment that the service provided was significant and separately identifiable.