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E/M and Chemo Same Day

  1. #1
    Default E/M and Chemo Same Day
    Clearnace Sale
    Hi fellow oncology coders,
    I am having problems with medical necessity denials for E/M and chemo same day. Our doctors review labs and toxicity of patients prior to their treatment, but there may not be anything specifically wrong with the patient other than signs or symptoms like weakness, fatigue, and/or pain related to the tx/disease. Can you still code this as a separately identifiable service to the chemotherapy treatment? Some times we hold treatment, or change their tx; but if they are coming in specifically for the tx and we are reviewing the toxicities is that inclusive?
    On another note if a patient is receiving chemotherapy that day are they automatically high risk (drug therapy requiring intensive monitoring for toxicity)?
    -Stephanie Thebarge, CPC

  2. #2
    Columbia, MO
    you may not bill an E&M on the same day as Chemo administration.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    For a cancer patient, if the face-to-face visit supports the level of service you are billing and the physician documents his follow-up with the patient, use modifier 25. A separate diagnosis is not required for reimbursement. The primary diagnosis for the encounter with chemo is V58.11. Also keep in mind that if the physician is following the patient, for example, with anemia, neutropenia, neuropathy, etc. that was present on the last evaluation, and is now resolved, you can code anemia, neutropenia, or neuropathy as primary reason for this follow-up, as AAPC coding assistants have advised. Our audits on this have passed medical necessity, and I believe if E&M is not a service billable/payable to medical oncology providers on the day of chemo treatment, they'd surely have to close their doors.
    Tonia Flohr, CPC, CHOC

  4. #4
    Columbia, MO
    When the purpose of the encounter is for chemo and the reason for the E&M is to look at the counts to verify that the patient can receive the chemo then this is not a billable service even with a 25 modifier. You should not use anemia for the E&M if this is not be treated on this encounter. Sorry but I disagree. Also V58.11 is a first-list only allowed dx code and cannot be secondary to an anemia code. And CMS has a transmittal on this where it is stated that this is not allowable.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    Correct, if the encounter is for chemo and a nurse checks the vitals, counts, and a review of symptoms, E&M 99211 cannot be billed. Payment for that service is bundled with the administration reimbursement and a modifier 25 is not applicable.

    I will do more research on coding "resolved" conditions. My instruction on that came from the AAPC discussion forum on an example of coding resolved pneumonia. It was stated that someone learned at a training event that if a follow-up visit is for a condition present at last visit, and it is resolved on the present visit, then code the condition again at this visit, and use a history of... code if needed on future visits for that condition. It was stated that this applies to coding resolved conditions. I have never coded follow-ups that way. I have coded resolved anemia as history of anemia. Does the instruction apply to anemia? Before I (or anyone else) becomes further confused or starts coding resolved conditions inappropriately, I'll need clarification on that.

  6. #6
    Columbia, MO
    The only conditions you may code as active when they come for a followup is infections. Otherwise once you kn ow a condition has resolved you do not code it.

    Debra A. Mitchell, MSPH, CPC-H

  7. Default E/M and Chemo Same Day
    We too are struggling with when it is appropriate to report an e/m in addition to chemo. CPT notes for this section state that physician work related to these codes predominantly involves affirmation of treatment plan and direct supervision of staff. CMS guidelines are not much more specific, other than stating that when svc is above and beyond typical pre/post therapy, a separately billable e/m is acceptable. Our docs perform/document a brief hx (how pt is feeling, reacting to meds, etc), followed by a comprehensive exam. Most have calculated these to be level 4/5 visits, appending mod 25. This seems to be standard of care at every chemo visit, which leads me to question the medical necessity. Occassionly they'll indicate assoc signs & symptoms (dehydrated, nausea, vomiting) and/or any underlying conditions (ie, anemia). Labs are drawn, followed by initiating the chemotherapy. After reading through the above publications a multitude of times, I've now confused myself. I would appreciate any/all other opinions/guidance on the issue, so I can give them a more educated answer.

    Thanks in advance!

  8. #8
    Recently, ASCO has become aware of issues regarding the coding of E&M services in conjunction with drug infusion codes. As a service to its members, ASCO has prepared a background document outlining the development of the drug infusion codes and their use in conjunction with an E&M visit. If you need additional information, please contact us at
    Check out this link, I found it to be a little more helpful when arguing medical necessity :
    Stephanie Thebarge, CPC, CEMC, CHONC
    Past Portland AAPC Chapter President
    Coding Compliance Specialist
    Feel free to message me with questions

  9. Default
    This is very helpful, and actually makes more sense in terms of RVU's associated w/chemo codes. It sounds like the "mini h&p" our docs are providing at their chemo visits, qualify for billing a separate e&m w/mod 25 after all. This document should be helpful in appealing any denials.


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