Clinch E/M Plus Chemo Pay Using These CMS Guidelines

Posted on 30. Sep, 2009 by Editor in Hot Coding Topics

Here’s why 99211 flashes a bright red ‘audit me’ sign at payers.

At roughly $60 a pop, missing just one 99213 service a day could cost your practice more than $15,000 a year. Use these official rules from Medicare to be sure you know when you should —and shouldn’t — add an E/M code to your therapeutic drug and chemotherapy administration claims.

Nip 99211-Based Denials in the Bud

Medicare will not pay 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) separately when you report it alongside the following:

• Chemotherapy or nonchemotherapy drug administration

• Diagnostic or therapeutic drug injection.

The Medicare Claims Processing Manual (MCPM), Chapter 12, Section 30.6.7.D spells this rule out for you.

The reason Medicare doesn’t reimburse 99211 separately is that CMS included “the work and practice expenses” of 99211 in the fees for administration codes 90760-90775 (renumbered as 96360-96375 on Jan. 1, 2009) and 96401-96425, according to the NCCI Policy Manual for Medicare Services, Chapter 11, Section N.3.

Example: Suppose a patient’s nausea complaint during chemotherapy requires a nurse assessment. The nurse consults the physician to adjust the pre-med order, but the physician doesn’t directly see the patient, proposes Kelly C. Loya, CPC-I, CPhT, senior consultant with Los Angeles-based Sinaiko Healthcare Consulting. This scenario might meet the basic definition of 99211, but you should not report 99211 in addition to the chemo admin code according to Medicare’s rule.

Similarly, patient questions or a therapeutic regimen change might prompt the nurse to provide additional 99211-level education on the administration day. But again you should not report 99211 in addition to the chemo code, Loya says.

Stay...

Tags: 174.1, 99211, 99213, chemotherapy, E/M, modifier 25, oncology, V58.11