Same Day E/M and Chemo

[Shay2025]

can someone please review this note and let me know if there was a seperately payable E/M done or was this simply inclusive to a chemo visit.

I need some type of documentation that states what exactly the note should say in order to bill for an E/M and Chemo on the same day.

View attachment chemo and em same day.pdf

 

[klevocz]

Same day E&M and Chemo

with a modifier yes

 

[Shay2025]

thx for your speedy reply.
I know you can use modifier -25 but what should the documentation say to qualify for the seperate E/M ?

 

[dtricia]

E/M same day as chemo

The Assessment and plan should reflect the status of ongoing issues. Are the problems stable, worsening or resolved? Was there an assessement of medications, noting changes? Are there new problems being worked up? With cancer the patients, the physicians are not only assessing their disease but the ongoing toxicity to chemo. They need to be constantly assessed to determine if the next infusion should proceed. They don't just have cancer, they have fatigue, pancytopenia, bleo lung, neuropathy...the list goes on.