Oncology & Hematology Coding Alert

Question: I use 99211 when patients are scheduled for chemotherapy, when no doctor visit is planned, and when nurses perform an assessment. However, I am receiving denials. Some third-party payers are requesting that we report modifier -25, but all others have paid in the past without it. What should I do?

Wisconsin Subscriber  
Answer: There are no hard and fast rules on coverage for third-party payers. Many follow Medicare guidelines on reimbursement policies, but this is not universal. Under Medicare, a level-one visit (99211) can be billed if the patient presents for a service (other than an injection) provided by a nurse. This includes visits for chemotherapy administration. The level-one visit is an incident to service and is billable to Medicare only if a physician is physically present in the office suite and available to provide immediate assistance. 
 
Third-party payers may impose other requirements, such as the use of modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). This must be appended to the E/M service code, while others pay the two codes separately.
 
It is important to establish a positive relationship with a provider representative for each of your major payers and work with them to clarify reimbursement policy and requirements. Use this information to develop a tool for your billing staff so they know what each payer requires. This will avoid unnecessary denials and payment delays.