A question regarding iron infusion coding

bgeiser

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Although I been a coder for many years, I have never coded hematology so my knowledge of it is limited.

I recently needed some treatment at a hematology/oncology practice for iron deficiency. I had three Venofer infusions that I believe were coded and billed incorrectly to my insurance and am interested in your input.

My initial visit was with a NP; I did not see the physician. This 99243 visit was billed under the group with the rendering provider as the physician, not the nurse practitioner.

My three subsequent visits were for infusion only and went like this...
The nurse comes into the waiting room, calls my name and as we walk back to the treatment room, there is small talk. I tell the nurse that I hope the iron helps with the severe fatigue I've been feeling. I sit in the chair, she gets the iron, connects it to me via a butterfly in the hand, I put in my earphones & enjoy music for the next hour. When the infusion finishes, she removes the needle, puts a bandaid on me and I'm on my way.

They were billed with: 99211, 36415, 96365, 96365 -SU -59, J1756 (300 units).

I don't understand the 99211 because everything I've read and every workshop I've attended states no 99211 with infusion, nor do I understand 36415 if there was not a blood collection. My understanding of why the second 96365 with modifiers SU and 59 was billed - a facility fee. The "facility" is a part of the same building; it is a large room filled with recliner chairs, IV pumps, etc where all infusions and chemotherapy treatments are done.

I discussed this with the office and they said 36415 is always used and that the nursing visit (99211) is valid because she asks how I am feeling.

Know I appreciate your time in reading this and responding to it.
 

trarut

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Do you mean the infusion suite is NOT owned by the medical practice? If the infusion suite is a hospital-based outpatient clinic, there are different rules. The 96365-SU and use of 99211 makes me wonder if this is the case. I believe nurse visits can be billed in the outpatient clinic setting if supported by documentation and I don't think "asking how you are doing" counts!

Now, talking provider-based coding/billing, if you came to my office as an established patient for an iron infusion only, you would be billed J1756, 96365 and 96366 (if the length of the infusion warrants it). 99211 is incidental to the drug administration code. Our infusion nurses ask every patient how they are; it's part of doing their job, not a billable service!

Access to place the infusion line is incidental to the drug administration code as well. 36415 is to report blood collection only and if you didn't have labs drawn, it should not be billed. (As we know, "always" =/= "right"!)

Personally, I would also question the appropriateness of a seemingly incident-to consult if you haven't done so already. It is billed as a consult so it appears you were either a new patient or an established patient referred for a new problem. If you never saw a physician, there's no support for a split/shared visit.

That's my $.02. Good luck.
 
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mitchellde

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Here is some info I found on the use of the SU modifier I thought you would find interesting:
.Claims are adjudicated and reimbursed based on the Place of Service. The CMS-1500 Claim Form contains a specific field (24-B) for Place of Service. Place of Service for “Office” or Physicians Office is “11”. Although item 24-D contains a space allotment for modifier use, no special consideration is given to the SU modifier; it is redundant to the numeric listed under the place of service column. Surgical Procedures::It is inappropriate to bill the surgical procedure CPT code on a separate line item, isting modifier “SU” and listing multiple units intended to cover the costs of surgical supplies.The Relative Value Units for the CPT procedure codes used to bill for the services rendered include the costs of running an office (practice expense).The medical supplies are included in the global allowance for each surgical procedure. Applicable HCPCS “J” codes (drugs administered other than oral) may also be billed separately.
Also you stated your initial visit was with the NP, was this a new patient encounter? If so then it cannot be billed under the physician as a shared encounter or as incident to. It was billed as a consult which can never be billed under another provider NPI.
What was the POS used? Was it an 11 or 22 or was it some thing else. A 99211 is not allowed to be used when the purpose of the encounter is to give an infusion. The nurses time to query you is included in the infusion code. You still must meet the 25 modifier requirement when billing any visit level with any other service. You will not meet these requirements for a scheduled procedure.
You may want to call your insurance rep and speak with them.
 
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bgeiser

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Thank you for your responses

I am most grateful for your responses.

The medical practice owns the suite where infusions are administered. As to place of service, it is 11.

You will both love this one...

I went to the office today so that blood could be drawn to check the effect of the infusions and, although I was not seeing anyone other than lab personnel, they wanted to charge me a 99211. I told them to give me a lab slip and went to a different lab.

My gut instinct and experience told me what is being billed is incorrect but I appreciate your input.

Bethann
 
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