We Bring The Pieces Together For You

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1 Modifier 25 Visit No how-de-do visits in Hematology Oncology MOASC Discussion of Meaningful Information Compliance Education We do it right. We Bring The Pieces Together For You

2 NBC Neltner Billing & Consulting Services, Inc Taylor Mill Road Independence, KY (800) (859) Martin E Neltner President cell mneltner@earthlink.net Grant Schuchmann Manager of Business Development cell Grant.Schuchmann@NeltnerBilling.com. PPT Disclaimer: The information contained within and through this presentation is the product of Neltner Billing and Consulting Services, Inc. ( NBC ). NBC provides this presentation and all content herein AS IS and without warranty, express or implied. NBC is not responsible for information presented and/or provided herein under any theory of liability or indemnity. All presentation materials are intended for educational purposes only. They are not intended as a substitute for any type or kind of professional services, products, advice, counsel or guidance. Persons and entities interested in engaging NBC for billing and consulting services should contact NBC directly for a written proposal and quote for services/products. For additional information about NBC, go to

3 Billing Expertise Billing and Coding Revenue Cycle Management Practice Management Process review and design Forms development Compliance audits and program development Documentation review Consulting, lobbying and advocacy Neltner Billing & Consulting Services Slide/Contents Subject to Disclaimer.

4 Agenda Compliance Disclosure Modifier 25 Defined Arguments Why The Visit Is Necessary Visit Is Separate From Infusion Time Performance Accounting Regulations

5 Compliance Make sure this talk is added to your compliance folder we gave you last year on the jump drive. If you do not have this file see a MOASC representative This seminar follows the OIG Voluntary Compliance Program Live Compliance every day

6 First Question Should Every Patient Be Evaluated In a Hematology / Oncology Practice?

7 How-de-do-visit Vitals and how are you feeling today That is it

8 Modifier 25 CPT Book Defined 2013 Edition Significant, Separately Identifiable E/M by the same physician or other Qualified Health Care Professional on the same day of the procedure or other service. Infusion is a service Above and beyond the usual pre-operative and post operative procedure

9 Modifier 25 CPT Book Defined 2013 Edition May be prompted by the symptom or condition A different diagnosis is not required

10 Argument for Modifier 25 Visits The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next encounter. Trailblazer E/M coding book page 18 December 2010 / ICN: What words can we choose to add to the note that confirms this risk associated with infusion therapy

11 Modifier 25 Presenting Problem CMS AMA Coding Book For a presenting problem with an established diagnosis, the record should reflect whether the problem is: - Improved, well controlled, resolving, or resolved - Inadequately controlled, worsening, or failing to change as expected or For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a possible, probable, or rule out diagnosis

12 Modifier 25 Definition The prior slide citation under the coding guidelines found in CMS E/M coding book Regulation example did not offer a comment about a stable patient that results from a Medical Necessary Visit by a Provider

13 Toxicity Assessment Refer to form in your compliance folder Chief Complaint and HPI Review of system based on Toxicity addresses at least four separate systems Exam? May or may not be needed touch the patient is good for the patient MDM is CBC review, treatment plan, orders etc.

14 CPT Book Three Categories `Preamble Argue A Provider Visit Is Medical Necessary 1. Hydration 2. Therapeutic, Prophylactic, & Diagnostic Injections and Infusions (Excludes Chemotherapy and Other Highly Complex Drug or Highly complex Biologic Agent Administration 3. Chemotherapy - read the AMA CPT preamble as it is full of information to support the argument for a separate provider visit

15 Modifier 25 Purpose was to deal with surgery or procedural coding that does not permit a separate visit on the day of the surgery or scheduled procedure Bone Marrow Procedure falls into this category

16 CPT Book Infusion Preamble Supporting Arguments For A Visit On The Day Of Assessment For Infusion 1. Requires direct supervision under hydration etc. 2. Requires periodic patient assessment which implies supervision under Therapeutic etc. section 3. Chemotherapy services are typically highly complex and require direct supervision next slide 1. Incident To rule mandates this for Medicare

17 Argument for Modifier 25 The AMA CPT Book preamble: Chemotherapy services are typically highly complex and require direct physician supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff. a different diagnosis is not required

18 When Is A Visit Not Required? When the physician decides it is not medically necessary? But the providers need to build the argument why it is necessary Example scenario Neulasta injection day after a visit What about Friday visit and injection is scheduled on Monday? What about multiple treatment days in the same week Pump disconnects Port flushes Coumadin visit Other injection visits Flu shots

19 Performance Accounting (PA) Work rvu and Practice expense drive your argument Regulations drive your argument Standard of care Oncology cost are higher than primary care PA

20 Modifier 25 Should Not Be Required for Infusion Therapy Physicians have been part of the Medicare Resource Based Health Care System, (RVU) since the early 1980s and this long standing policy of the patient assessment offers insight from a payment policy, why a provider visit is always needed. Modifier 25 is appended to every visit associated with infusion therapy in a private office simply because other services are offered on the day the infusion is approved. Technically speaking the only reason for the modifier 25 is to allow the claim to pass the edits when two or more services are billed on the same claim. In reality, modifier 25 should not be required since this is the policy when the service is billed in a hospital setting

21 Argument for Modifier 25 Performance Accounting Foundation for Relative Value Unit of Work Professor W.C. Hsiao, author of the Relative Value System (RVU) which CMS relies on to reimburse providers identified four elements of physician work as 1) Time, 2) Mental effort and judgment, 3) Technical skill, 4) Physical effort, and Psychological stress. (September 28, 1988 WC Hsiao the famous Harvard professor who created the RVU system for Medicare) E/M work and practice expense applies to all specialists by the level of the code as it relates to the four elements above. This supports that the bell curve for the specialty of Hematology/Oncology would be higher due the nature of the non-specialty guidelines. This supports that every patient should be evaluated before they receive complex infusion drugs. The best example for Hematology/Oncology coding is a comprehensive history and exam that concludes with a stable patient cleared for infusion therapy

22 Visit is Separate From Infusion Supervision RVU are different next two slides verify this Time period is different Location of service may be different Provider vs. nurse how-de-do If nurses are performing initial toxicity assessment then providers should be seeing patient Nurses toxicity assessment is a clinical compliance verification needed before the infusion begins

23 Visit Value Code M od Description Work NF PE Fac PE NF Tot Fac Tot work total Private Private Practice loc hospital Practice loc hospital 11 location location 22 work private office total location 11 hospital total loc OFFICE/OUTPATIENT VISIT EST $ $ $ OFFICE/OUTPATIENT VISIT EST $ $ $ OFFICE/OUTPATIENT VISIT EST $ $ $ OFFICE/OUTPATIENT VISIT EST $ $ $

24 Supervision Value Code Performance Accounting techniques M o d Description Work NF PE Fac PE NF Tot Fac Tot work total CHEMO IV INFUSION 1 HR $ $ CHEMO IV PUSH ADDL DRUG $ $ THER/PROPH/DIAG INJ IV PUSH $ 9.90 $ THER/PROPH/DIAG INJ IV PUSH $ 9.90 $ Total infusion reimbursement $ Supervision time $ Supervision time ratio 12% Separation of supervision from visit

25 Table 2 E/M Coding Audit Under Management Options Now This Is A Interesting Comment Important Note: These tables are not all inclusive. The entries are examples of commonly prescribed treatments and the point values are illustrative of their intended quantifications. Many other treatments exist and should be counted when documented. Do not count as treatment option s notations such as: Continue same therapy or no change in therapy (including drug management) if specified therapy is not described (record does not document what the current therapy is nor that the physician reviewed it). Drug management, per problem. Includes same therapy or no change in therapy if specified therapy is described (i.e., record documents what the current therapy is and that the physician reviewed it). Dose changes for current medications are not required; however, the record must reflect conscious decision-making to make no dose changes in order to count for coding purposes. 1 >3 new or current medications per problem

26 Initiation of or Changes in Treatment The initiation of, or changes in, treatment should be documented. Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies, and medications. If referrals are made, consultations requested, or advice sought, the record should indicate to whom or where the referral or consultation is made or from whom advice is requested.

27 CPT Modifier 24 CPT Modifier 24 Unrelated evaluation and management service This modifier may be used to indicate that an Evaluation and Management (E/M) service or eye exam, which falls within the global period of a major or minor surgery and which is performed by the surgeon, is unrelated to the surgery The global period of a major surgery is the day prior to, day of and 90 days after the surgery. Note that although the CPT description of CPT modifier 24 reflects postoperative,' you may submit this modifier for a visit performed the day prior to a major surgery when the visit is unrelated to the surgery. This modifier may only be submitted with E/M and eye exam codes CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. February 2011 Railroad Medicare ~ Palmetto GBA

28 Modifier 24 Railroad Medicare and other are comingling modifier 24 and modifier 25 Systems may be internally changing modifier to fit their screens Be prepared to ask if this is happening when you receive a denial

29 AMA Citation That Validates the Need for a Provider Visit The E/M service may be caused or prompted by the symptoms or conditions for which the procedure and/or service was provided.

30 Argument for Modifier 25 in a Community Based Practice If a physician practices in a hospital setting as a hospital employee or as a contractor where the hospital bills the drugs, and infusion services the provider does not have to append the modifier 25 to the visit when the patient is evaluated on the same day presented for infusion therapy

31 ASCO Supports Use of Modifier 25 American Society of Clinical Oncology ASCO letter copy enclosed that supports the routine use of the modifier 25 pended to an evaluation on the day of infusion therapy

32 Visits In The Infusion Area Providers must keep these encounters separate The Visit is to assess the patient ( not a how-de-do visit. If it is then you cannot bill a visit. The supervision is different and distinct and is reserved for provider over site during the infusion. ( Incident To Requirement

33 Separate Evaluations In The Infusion Area Required By Provider Due To Space Constraints If space is a problem. Have a policy provider does not have enough office space to evaluate patients in office area. Accessing ports or line for blood in infusion area And you continue fluid flow until CBC is reviewed then this is for convenience Cannot count fluid management time for infusion therapy When the provider approves the therapy Once any infusion begins the evaluation is completed and the supervision time takes over. Any evaluations during infusion time is part of the infusion work rvu

34 Regulation Citations CMS transmittal 731. We also cite the CMS Standalone policy that each patient encounter with a provider is separate and cannot be linked to another service

35 Regulation Citations Pub Chapter 12, 23, and 30 Pub Program Integrity Chapter 3 and 30 Medicare Claims Processing Manual : Chapter 12 - Physicians/Non physician Practitioners Payment for Evaluation and Management Services Provided During Global Period of Surgery CPT Modifier Significant Evaluation and Management Service by Same Physician on Date of Global Procedure Carriers pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure. More to read by you all get the picture They are putting infusion therapy in the same category as surgery. Ouch

36 Summary Understand that you will have issues with modifier 25. Its like taxes and death IT S A FACT OF LIFE AND YOU WILL HAVE TO RESPOND WITH CITATION, ARGUMENTS, AND PASSION THAT BILLING THE VISIT IS MEDICALLY NECESSARY, SEPARATE AND DISTINCT AND DOESNOT REQUIRE A SEPARATE DIAGNOSIS SOLUTION: When the payer adds a level five visit allowed in the infusion initial code and increases this code by this level then and only then would we consider dropping the visit from the day of infusion therapy.

37 Coming Soon Hematology / Oncology Evaluation and Management Coding and Audit Guide Oncology Specialty audit template Example notes Meaningful value statements Outcomes

38 Reference Medicare Internet Only Manual Publication 100-4: Claims Processing Chapter 12: Physician Services Section 30.6: E&M Coding #TopOfPage PPT Disclaimer: The information contained within and through this presentation is the product of Neltner Billing and Consulting Services, Inc. ( NBC ). NBC provides this presentation and all content herein AS IS and without warranty, express or implied. NBC is not responsible for information presented and/or provided herein under any theory of liability or indemnity. All presentation materials are intended for educational purposes only. They are not intended as a substitute for any type or kind of professional services, products, advice, counsel or guidance. Persons and entities interested in engaging NBC for billing and consulting services should contact NBC directly for a written proposal and quote for services/products. For additional information about NBC, go to

39 Questions and Downloads Please use the Facebook forum below to submit questions to Marty directly. He will respond within 24 hours. Please click the link below in order to download the Power-Point version of these slides. To gain immediate access Neltner s FREE resources, the: 1. 5-page, commercial payor, citation letter 2. ASCO support letter Submit your name and to the right and you will be directed to download them immediately. They are available for your immediate use. PPT Disclaimer: The information contained within and through this presentation is the product of Neltner Billing and Consulting Services, Inc. ( NBC ). NBC provides this presentation and all content herein AS IS and without warranty, express or implied. NBC is not responsible for information presented and/or provided herein under any theory of liability or indemnity. All presentation materials are intended for educational purposes only. They are not intended as a substitute for any type or kind of professional services, products, advice, counsel or guidance. Persons and entities interested in engaging NBC for billing and consulting services should contact NBC directly for a written proposal and quote for services/products. For additional information about NBC, go to