Private And Hospital Based Oncology Practice Patient Visits And Chemo Supervision Are At Risk For Al

Did you know that private and hospital based oncology practice patient visits and chemotherapy supervision are at risk for alleged “double dipping”? I believe this can lead to a fraudulent claim billed to insurance companies.

There is a misunderstanding regarding what Provider Evaluations requirements are to needed to evaluate the patient on the day of scheduled infusion therapy and what requirements are needed to adequately supervise patients who receive infusion therapy in hospital or office settings.

Physician work relative value units are part of all the infusion CPT codes, which creates a payment for the provider supervision of the service. The work payment is between $45 to $90, depending how many codes are used during the episode of infusion care. This suggests a mid-level provider or physician must evaluate every patient for a scheduled infusion, and no office service can be billed for that brief evaluation required as a part of evidence of supervision. The key word in the regulations is centered around “routine” chemotherapy.

There is a need to clarify the definition of “routine”. For example, is “routine” limited to patients who report on the day of a scheduled infusion or injection with no symptoms, or does it now include patients who present with symptoms of prior treatments? The recent CMS guidelines suggest that related symptoms to the infusion therapy is part of the “supervision” requirement.

It appears permissible to bill a separately identifiable evaluation (office visit) on the day of a scheduled infusion or injection for patients who present with unrelated symptoms, etc. However, it is not clear when the provider should 1. evaluate the patient as a “separate identifiable” visit as the modifier 25 suggests. 2. when the provider should offer a supervision evaluation that is not billable. 3. how does this issue apply to providers who are employed by hospitals since there is no requirement to code an office visit with a modifier 25 as the infusion codes are billed to the Medicare Intermediary? Whereas the office visit is billed to the Medicare carrier.

It appears the modifier 25 is a product of only billing as an office base provider, so does the “when to bill for a separate office visit” regulation only apply to those providers who practice in a private office setting commonly referred to as location 11 on the CMS billing form? Or does it apply to any physician, any location that provides evaluations and supervision services?

I recently published a white paper that fully explains the issues and what providers should be doing to avoid requests for refunds for nursing staff evaluation of patients on a scheduled day of infusion therapy (commonly referred to as the How-de-do visit). Stay tuned.

#infusioncare #infusionCPTcodes #modifier25

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