Question Same day E/M and Infusion.

Mwatts

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We are a large system with both facility, outpatient facility and Medical groups, Our pediatric oncology group feels they can report a high level E/M service on the same day as a infusion service such as 96440 or 96401. We have provided resources that the E/M is only allowed when Modifier 25 is met such as treating signs and symptoms etc. but not warranted when used to determine patients fitness to undergo treatment. They also feel the MDM for infusions can be used to support High MDM. In our case the infusion is reported in our Outpatient Facility ID and the E/M from our medical office tax id.

Does anyone also work in a similar situation and have any additional guidance regarding the E/M on the same day as an infusion?
 

SharonCollachi

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As I said elsewhere, my mom has been a patient of a cancer center for almost two years. I was talking to one of the staff there about how we instituted a rule at our office that nothing happens at a monthly pain management visit except: how have things been over the past month, how are things right now, and what do we need to do for the next month. No trigger point injections, joint injections (we will do a "pain shot" if needed), no reviewing MRI images, etc. If the patient needs injections, or has images to review, we book a separate appointment on a separate day; otherwise, no matter what our documentation says, no matter what the modifiers are, the trigger points will get paid and not the visit. This was a change in the last year that a number of our commercial payers announced.

So the staff member I was talking to said they have had to do the same thing at the cancer center. The patient meets with the physician on day one, gets labs done (in-house), and comes back the next day for infusion, chemo, etc. They stopped doing it on the same day because they were fighting too many battles over getting both paid on the same day.
 

Mwatts

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As I said elsewhere, my mom has been a patient of a cancer center for almost two years. I was talking to one of the staff there about how we instituted a rule at our office that nothing happens at a monthly pain management visit except: how have things been over the past month, how are things right now, and what do we need to do for the next month. No trigger point injections, joint injections (we will do a "pain shot" if needed), no reviewing MRI images, etc. If the patient needs injections, or has images to review, we book a separate appointment on a separate day; otherwise, no matter what our documentation says, no matter what the modifiers are, the trigger points will get paid and not the visit. This was a change in the last year that a number of our commercial payers announced.

So the staff member I was talking to said they have had to do the same thing at the cancer center. The patient meets with the physician on day one, gets labs done (in-house), and comes back the next day for infusion, chemo, etc. They stopped doing it on the same day because they were fighting too many battles over getting both paid on the same day.


guidelines for modifier 25 would state that It would be inappropriate to bring the patient back another day for something that could be done at the encounter for the reason to increase billing. I cant bring the patient back tomorrow for a joint injection today because my E/M doesn't support significantly separate.
 

thomas7331

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Modifier 25 guidelines don't really apply in the situation you have described here. If the infusions are being performed in a facility and billed on a UB-04 facility claim, and the physician is evaluating the patient separately in a medically necessary encounter and billing a professional fee on a 1500 form, then there is not going to be a modifier 25 since the services are not even on the same claim and are being billed by two different providers and provider types. There shouldn't be an issue with getting an E&M paid on the same date in this scenario. Or am I missing something?
 
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SharonCollachi

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guidelines for modifier 25 would state that It would be inappropriate to bring the patient back another day for something that could be done at the encounter for the reason to increase billing. I cant bring the patient back tomorrow for a joint injection today because my E/M doesn't support significantly separate.

They are not coming in for joint pain. They are coming in for chronic pain which is managed on a monthly basis. The doctor spends about 30 minutes with each patient on this monthly visit. The joint injection is definitely a separate service, but the payers are not recognizing the work of 30 minutes of care for a patient with chronic pain. It's not to increase billing, it's to get paid for the work that is done, and that they used to pay for, before they decided that for most offices, the patient WOULD be coming in for a new problem that is only joint pain. They don't factor in that we are a practice that is a specialist for chronic pain.
 

Mwatts

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Modifier 25 guidelines don't really apply in the situation you have described here. If the infusions are being performed in a facility and billed on a UB-04 facility claim, and the physician is evaluating the patient separately in a medically necessary encounter and billing a professional fee on a 1500 form, then there is not going to be a modifier 25 since the services are not even on the same claim and are being billed by two different providers and provider types. There shouldn't be an issue with getting an E&M paid on the same date in this scenario. Or am I missing something?
Same provider.... Sorry forgot to indicate that.
 

beehall

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We are a large system with both facility, outpatient facility and Medical groups, Our pediatric oncology group feels they can report a high level E/M service on the same day as a infusion service such as 96440 or 96401. We have provided resources that the E/M is only allowed when Modifier 25 is met such as treating signs and symptoms etc. but not warranted when used to determine patients fitness to undergo treatment. They also feel the MDM for infusions can be used to support High MDM. In our case the infusion is reported in our Outpatient Facility ID and the E/M from our medical office tax id.

Does anyone also work in a similar situation and have any additional guidance regarding the E/M on the same day as an infusion?

We are a large system with both facility, outpatient facility and Medical groups, Our pediatric oncology group feels they can report a high level E/M service on the same day as a infusion service such as 96440 or 96401. We have provided resources that the E/M is only allowed when Modifier 25 is met such as treating signs and symptoms etc. but not warranted when used to determine patients fitness to undergo treatment. They also feel the MDM for infusions can be used to support High MDM. In our case the infusion is reported in our Outpatient Facility ID and the E/M from our medical office tax id.

Does anyone also work in a similar situation and have any additional guidance regarding the E/M on the same day as an infusion?
Mwatts, Could you provide a link to the resources you mentioned?
 
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