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Do not bill E/M with drug administration charge when an infusion is the sole reason for the visit

APCs Weekly Monitor, June 1, 2007

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QUESTION: We need some clarification on the proper way to bill for chemotherapy and other drug injections and infusions in the ED when clinical staff perform a drug administration service and no other procedures. My question is this: "Is it appropriate to bill an ED visit charge (99282-99285) and a code for the initial drug administration service (with modifier -25)?" Appending modifier -25 to the line item gets the bill through in most cases; however, in reading the documentation, I am not sure that this is the appropriate way to bill.
 
If the answer to the above question is "no", then when staff only perform a drug administration procedure, are we allowed to bill for the ED visit only (which has a higher reimbursement rate), or are we required to bill for the drug administration charge without the ED visit charge?
 
ANSWER: The key is to ascertain the reason the patient presented to your ED. If he or she presented to the ED specifically for an injection or infusion, that is the purpose of the visit and that should be the only charge you report. In these instances, the E/M of the procedure is included in the reimbursement for that procedure.
 
It is inappropriate to bill an additional E/M (visit) charge unless the patient suffers a complication that requires an E/M beyond the typical scope of that procedure. For example, if during a chemo infusion, a patient became short of breath and staff performed E/M of that condition, you could bill a separate charge for a visit based on your ED level criteria.
 
In last year's OPPS final rule, CMS provided the following instruction: "Providers should bill a low-level visit code in such circumstances only if the hospital provides a significant, separately identifiable low-level visit in association with the packaged service". Do not bill a visit charge in place of a procedure charge. To do so simply to increase reimbursement is fraudulent and could subject your facility to penalties.
 
One Medicare FI published a helpful frequently-asked-questions document in 2004. In it, the FI described that physicians occasionally instruct their clinic patients to seek follow-up care in the ED because the patient can only come in after clinic hours. The FI's guidance was to bill these services as clinic services provided in a treatment room, not an ED visit.
 
Note that when a patient reports to the ED because he or she is sick (not specifically for an infusion), the physician/nursing staff will perform an E/M service. As a result of the evaluation, staff may then decide the patient needs an infusion. In this case, it is appropriate to report a facility E/M and an infusion charge.

As always, check with your FI for official guidance.

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