Part B Insider (Multispecialty) Coding Alert

Published on Mon Mar 15, 2004 PDF

But you can bill higher level visits for unrelated conditions

If a patient comes in just for chemotherapy, you'll receive a higher RVU for administration -- but you may not be able to bill separately for evaluation and management.
 
According to the new Medicare physician fee schedule, Medicare won't pay a level one visit (CPT 99211 ) on the same day as chemotherapy administration or non-chemotherapy infusion any more -- even if the E/M service is "unrelated to the drug administration."

"They added to the RVUs for the physician work for the [chemotherapy] drug administration codes. That's why you no longer bill the 99211," says coder Ris Marie Cleland with Oplinc Oncology in Lawton OK.

You'll actually receive more money billing 96408 (Chemotherapy administration, intravenous; push technique), instead of 99211, says Arlee Session, corporate clinical executive of Forum Health's CancerCare in Youngstown, Ohio. You can bill 96408 multiple times if the physician uses multiple drugs, but you can submit 99211 only once per visit.

But if you provide a higher level and separately identifiable E/M service on the same day as chemotherapy, Medicare should reimburse it even without special explanation, the American Society for Clinical Oncology says in a FAQ on its Web site. Just make sure the documentation justifies the level of service being provided. If you provide a higher level E/M visit along with non-chemotherapy infusion codes 90780-70781, then you should use the -25 modifier, ASCO says.

But even if the physician correctly documents all the aspects of a higher level E/M visit, it still won't get paid unless it's medically necessary, notes Cleland. "Let's say they're having chemotherapy, and the doctor every single time comes in and sees the patient and performs a level four E/M visit." The documentation could be picture-perfect, but Medicare may still decide the visits weren't necessary.

The key thing is to read the description of the -25 modifier ("significant, separately identifiable E/M service...") and make sure it really applies in this circumstance, Cleland adds. Even if the patient needs additional assessment before chemotherapy, Medicare will consider that part of the chemotherapy administration.