Diagnosis: 714.0
Modifier -25 is used to indicate that the patient required a significant, separately identifiable E/M service on the same day as the patient received a minor procedure. E/M services that result in the decision to perform a procedure on the same day are considered to be part of the evaluation for the procedure and are not separately billable. However, this patient had a separate problem (pain and swelling of the knees), which required E/M services, therefore the portion of the encounter related to the diagnosis and treatment of the patient’s pain are separately billable with the use of modifier -25.
The E/M services related to the patient’s knee pain included:
- Expanded problem-focused history;
- Detailed exam; and
- Low complexity decision making—established problem; worsening, lab and X-ray ordered, and one or more chronic illness with mild exacerbation.
The abatacept infusion would be coded as 96413, not 96365. The CPT definition states that, “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. Typically, such chemotherapy services require advanced practice training and competency for staff who provide these services; special considerations for preparation, dosage, or disposal; and commonly, these services entail significant patient risk and frequent monitoring.”
Abatacept falls under this portion of the definition because it requires direct physician supervision. There have been rare cases of anaphylaxis or anaphylactoid reactions in patients receiving abatacept, as well as other events potentially associated with drug hypersensitivity such as hypotension, urticaria, and dyspnea. Physicians should exercise caution when considering abatacept in patients with recurrent infections and underlying conditions that may predispose them to infections, or chronic, latent, or localized infections. Specially trained staff should be available to monitor these patients and should be able to deal with potential reactions.
