Wiki modifier 25 for physician E/M on same day as chemo?

ens555

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Good evening, I'm told to add modifier 25 to physician E/M when patient has chemo on same day. Would someone please explain why? The physician is not billing the chemo administration. Many thanks
 
I have 2 questions about this:
1) Who is telling you to add -25 and what is their reasoning?
2) Who is billing the chemo administration? If it's another physician of the same specialty who is part of your same group, then I totally understand why -25 on your claim as they will get bundled. But if you are a GI and the hem/onc is billing chemo, there should be no reason for -25.
 
Good evening, I'm told to add modifier 25 to physician E/M when patient has chemo on same day. Would someone please explain why? The physician is not billing the chemo administration. Many thanks
Chemo admin is billed by facility side; both profee & facility codes are on the bill when I work on it. The Teams training video indicated modifier 25 on the profee E/M (sometimes there is a separate MD visit) when chemo is administered the same day. I believe the knowledgeable trainer misinterpreted the edits in 3M with regard to modifier 25. Clearly modifier 25 would be applied when there is a facility E/M on the same day as chemo administration. I thought the profee provider had to do a qualifying procedure in order to apply modifier 25 to the profee provider E/M. I am looking at the revenue codes & do not see any profee procedures. ( I am primarily a facility coder). Thank you again.
 
If the physician is providing a visit in the facility, then a profee E&M is appropriate, but no -25 should be required. Those profee and facility bills will NOT be on the same claim to insurance.
I cannot provide any guidance regarding the facility end of things as I have no experience in that.
 
Chemo admin is billed by facility side; both profee & facility codes are on the bill when I work on it. The Teams training video indicated modifier 25 on the profee E/M (sometimes there is a separate MD visit) when chemo is administered the same day. I believe the knowledgeable trainer misinterpreted the edits in 3M with regard to modifier 25. Clearly modifier 25 would be applied when there is a facility E/M on the same day as chemo administration. I thought the profee provider had to do a qualifying procedure in order to apply modifier 25 to the profee provider E/M. I am looking at the revenue codes & do not see any profee procedures. ( I am primarily a facility coder). Thank you again.
I agree with @csperoni here, there's no need for a modifier 25 on the physician's professional claim when the facility is billing the chemo. The physician only needs the modifier when there is another physician procedure or service being performed and billed on the same date.

I also agree with your interpretation on the facility side. If the physician is seeing the patient in a provider-based department of the facility and the facility is billing a clinic charge for that visit (e.g. G0463), then a modifier 25 will be required on that charge on the facility bill. However, the modifier would need to be supported by documentation that shows that this is a service that is above and beyond the usual pre- and post-procedural work involving the chemotherapy service. So, for example, if the physician is performing a full 'office visit' type of service involving the clinic staff prior to or after chemo, then the modifier may be valid. But if the physician is simply evaluating the patient during the course of the drug administration and there is no facility resource involved in that E/M service, then the facility shouldn't be billing for it.
 
Here is the reference I was given by the knowledgeable trainer, from the NCCI manual. And thanks for the replies.

8. The drug and chemotherapy administration CPT codes 96360-96375 and 96401- 96425 have been valued to include the work and practice expenses of CPT code 99211 (Evaluation and Management (E&M) service, office or other outpatient visit, established patient, level I). Although CPT code 99211 is not reportable with chemotherapy and non-chemotherapy drug/substance administration HCPCS/CPT codes, other non-facility-based E&M CPT codes (e.g., 99202-99205, 99212-99215) are separately reportable with modifier 25 if the physician provides a significant and separately identifiable E&M service. Since providers/suppliers shall not report drug administration services in a facility setting, a facility-based E&M CPT code (e.g., 99281-99285) shall not be reported by a provider/supplier with a drug administration CPT code Revision Date (Medicare): 5/1/2022 XI-5 unless the drug administration service is performed at a separate patient encounter in a nonfacility setting on the same date of service. In such situations, the E&M code should be reported with modifier 25. F
 
Here is the reference I was given by the knowledgeable trainer, from the NCCI manual. And thanks for the replies.

8. The drug and chemotherapy administration CPT codes 96360-96375 and 96401- 96425 have been valued to include the work and practice expenses of CPT code 99211 (Evaluation and Management (E&M) service, office or other outpatient visit, established patient, level I). Although CPT code 99211 is not reportable with chemotherapy and non-chemotherapy drug/substance administration HCPCS/CPT codes, other non-facility-based E&M CPT codes (e.g., 99202-99205, 99212-99215) are separately reportable with modifier 25 if the physician provides a significant and separately identifiable E&M service. Since providers/suppliers shall not report drug administration services in a facility setting, a facility-based E&M CPT code (e.g., 99281-99285) shall not be reported by a provider/supplier with a drug administration CPT code Revision Date (Medicare): 5/1/2022 XI-5 unless the drug administration service is performed at a separate patient encounter in a nonfacility setting on the same date of service. In such situations, the E&M code should be reported with modifier 25. F
Yes, but NCCI rules apply to codes that are submitted together on the same date by the same provider. If the E&M code is on a professional claim and the chemotherapy is on a facility claim, then these are two different providers and the modifier would not be necessary. That said, it's not hurting anything if you put it on the physician's charge anyway, so if your organization is telling you to do it, I would just go ahead and do what they say and not worry too much about it.
 
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