Wiki Chemo, labs, and E/M mod. 25

[klursky]

Does anyone know when chemotherapy is held/cancelled due to labs being higher than the parameter, can you bill for E/M with modifier 25 with the labs? Labs are always performed prior to infusions/injections and a nurse has to review the lab results prior to chemo, but if labs are not satisfactory, infusions/injections are cancelled. Would it be appropriate to bill for an E/M level w/mod 25 with the lab charges all on the same day? I am unable to locate any CMS guidelines for this particular scenario. Any help is greatly appreciated. TIA!

Documentation: male presenting for weekly epoetin alfa-epbx (Retacrit) SQ injection. No Retacrit was given due to Hct is higher than parameter.​

Pt was ambulatory. ​

Hgb=10.4, Hct=33.4 today. No Retacrit was given. Last Retarrit was given on 7/13/23. Pt did not need Retacrit last 3 weeks. The PA, was notified at 4 pm. The PA said pt can do every 2 weeks. Schedule was updated to Retacrit every 2 weeks. ​

Patient Education Received/ Reinforced: Yes​

Was Physician notified for any reason:Yes​

If Yes, list any outcomes from the conversation (dose modification, additional orders): See notes above.​

​

PATIENT EDUCATION​

*Follow-up teaching session was provided for patient XXX on 8/10/2023. Patient readiness to learn is high.
Participants present: patient.​

*Barriers to learning: no barriers to learning identified.​

*Teaching methods used: verbal instruction.​

*Discussion topics: DISEASE AND TREATMENT: laboratory values, medication/adverse effects and treatment plan, SYMPTOM MANAGEMENT: fatigue and SELF CARE: what to report to MD/RN.​

*Education resources given: Chemotherapy calendar.​

*Patient response to education:verbalized understanding.​

*Time spent :11-20 minutes​

 

[CBLENNIE]

It is unclear from your visit note whether the patient was actually seen by the PA or physician, there are just the following statements made regarding the PA & physician.

Pt did not need Retacrit last 3 weeks. The PA, was notified at 4 pm. The PA said pt can do every 2 weeks. Schedule was updated to Retacrit every 2 weeks. ​

Was Physician notified for any reason: Yes​

In the Patient Education section of the note, it does not indicate who did the education, was it the PA, the physician, or some other clinical staff member. Who is the provider that saw the patient who you would be billing an E&M for? If the PA actually saw the patient, then it appears you have the necessary information documented to bill for an E&M. However, from an insurance company auditor standpoint I don't think I we would consider it appropriate to bill for an E&M without it being clearly documented who provided services to the patient on this DOS.

Unless you are just looking at billing a 99211 for a nurse visit, then you are likely in the clear to bill the E&M, which would not require the modifier 25 since the only other services provided were labs which are subject to bundling with the E&M.

 

[klursky]

It is unclear from your visit note whether the patient was actually seen by the PA or physician, there are just the following statements made regarding the PA & physician.

Pt did not need Retacrit last 3 weeks. The PA, was notified at 4 pm. The PA said pt can do every 2 weeks. Schedule was updated to Retacrit every 2 weeks. ​

Was Physician notified for any reason: Yes​

In the Patient Education section of the note, it does not indicate who did the education, was it the PA, the physician, or some other clinical staff member. Who is the provider that saw the patient who you would be billing an E&M for? If the PA actually saw the patient, then it appears you have the necessary information documented to bill for an E&M. However, from an insurance company auditor standpoint I don't think I we would consider it appropriate to bill for an E&M without it being clearly documented who provided services to the patient on this DOS.

Unless you are just looking at billing a 99211 for a nurse visit, then you are likely in the clear to bill the E&M, which would not require the modifier 25 since the only other services provided were labs which are subject to bundling with the E&M.

Thank you for your help, it is greatly appreciated. For clarification, it is a nurse visit in the HOD clinic who reviewed the labs and provided the education. The nurse did speak with the PA and we are only looking to bill the 99211 for this.