Question Z51.11 with E/M Visits


Phoenix, AZ
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Hi everyone,

I work in at a pediatric hospital in ProFee. We are having some debate on this code as it pertains to our coding. We code for E/Ms and only procedures like 96450 and bone marrow aspirations/biopsies. I believe the facility charges for in clinic IV chemo. I have been told to use Z51.11 as a primary dx for the office visits when patients receive chemo. They do receive chemo after an office visit. My argument is that patient are usually seen by the doctor to go over more issues than the neoplasm or leukemia. Other issues include side effects of chemo and other manifestation of the neoplasm or other chronic conditions. Therefore the reason for the office (99212-99215) is not SOLELY for chemo. Sometimes they are seen for just chemo and little to no issues exist alongside or are not an issue.

Would it just depend on the HPI/reason for visit in the note? Or is solely for chemo OK to use in E/M when patient receives chemo regardless of other issues? It's hard to find info for this as the guideline for the code in my opinion is intentionally vague. If any insight could be shared, that'd be great. (other than copying and pasting the guideline which does nothing)


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You are correct, the E/M level is based on the medical necessity. The reason for the visit , HPI, Exam and MDM. You can append a 25 modifier on the E/M if they have an infusion on the same day.
Also, I would use a more specific and a better dx for the office visit. If they are only coming in for Chemo, no office visit , only the infusion is to be billed. However, some practice bill for a 99211 with
the infusion if they had seen the nurse.