# How to document admit for chemo?



## renifejn (Jan 26, 2009)

What would be a good way for physicians to document (to get 4 HPI) an admit for chemo only?   Pt with ALL is admitted for chemo...no other complaints.

Thanks


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## LLovett (Jan 26, 2009)

I don't have any providers currently doing this but I would think you could have

Location
Duration
Severity
Modifying Factors
Assoc Signs & Symptoms

But that is just a guess on my part. The most important thing is for the provider to do what is medically necessary and then document what they have done. If they only get 2 or 3 elements of HPI so be it, it is what it is.

Good luck,

Laura, CPC


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## renifejn (Jan 26, 2009)

Thanks for your response, but I have one question to that---if they only get 2 or 3 then they havent even reached a detailed HPI and an admit is not billable?


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## LLovett (Jan 26, 2009)

I asked that question too and the response I got was 

"When you dont' have sufficient documentation to meet the standard for a 99221, use EITHER the unlisted E/M procedure code: 99499 -or- 99221-52 (reduced service modifier). This came from a seminar I attended, and was carrier specific. Some carriers wanted the 99499, others wanted the -52 modifier on the 99221." 


This is what I am going to do with the ones I run across that don't meet requirements but as yet I have not submitted any this way.

Laura, CPC


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## FTessaBartels (Jan 26, 2009)

*INpatient or Observation?*

Is the patient truly be admitted as an inpatient for chemo?  Or is the patient being admitted to observation status?

99218 Initial observation care can be coded with a detailed history.

I would think the HPI elements would focus on: Quality, Severity, Duration, Modifying factors, Associated Signs & Symptoms. ALL being a systemic disease, I'm not sure how you'd get location. 


F Tessa Bartels, CPC, CEMC


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## renifejn (Jan 26, 2009)

Kids are being admitted as inpatients for 2-3 days for chemo w/ ALL ( most common dx)..

So, what can they write?

so what is the quality, severity, etc?  can you give examples?


4 y/o with ALL (acute--using this as quality??) diagnosed in 12/2008 (duration??) being admitted for chemo (modifying factor???).  No pain or n/v (s/s??)

Please help me get on the right track so i can help these docs document properly? 


thanks for your help


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## LLovett (Jan 26, 2009)

Location would be where the cancer is. In this example blood and bone marrow.


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## renifejn (Jan 26, 2009)

I dont know if I exactly agree with that, but I welcome input from others in case I'm wrong.

Thanks


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## FTessaBartels (Jan 26, 2009)

*Example of HPI*

You cite as an example: *4 y/o with ALL (acute--using this as quality??) diagnosed in 12/2008 (duration??) being admitted for chemo (modifying factor???). No pain or n/v (s/s??)*

I agree with your thinking - acute would be quality; diagnosis date shows duration; chemo is a modifying factor; no pain is an associated sign/symptom.

Another example:
4 y/o with ALL stage 2, diagnosed Oct 2008, being admitted for second round of chemotherapy. Counts have improved since first dose. Patient complained of nausea with first dose, but controlled with Zofran. 
 (ALL = quality / stage 2 = severity / Oct 2008 = duration / chemo & Zofran = modifying factors / counts improved = quality / nausea = associate sign/symptom)

Hope this helps. 

F Tessa Bartels, CPC, CEMC


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## FTessaBartels (Jan 27, 2009)

*Conseling/Coordination*

Just a thought ...
If your physician is spending any length of time speaking w/ patient and parents about the course of chemo being undertaken - risks, benefits, side effects, etc ... you might be wise to advise them to bill based on time.

The note should include:
Total time spent with the patient (and family)
Amount of time spent in counseling /coordination of care (must be >50% of total)
Substance of the C/C.

For example:  I spent 50 minutes with Johnny and his parents. 25 minutes of this time was spent in counseling/coordination of care, discussing the recommended course of chemotherapy, potential risks and benefits, hoped-for outcomes, possible side effects. 

This would qualify for a 99222 without any exam or HPI.
99221 - 30 minutes
99222 - 50 minutes
99223 - 70 minutes

F Tessa Bartels, CPC, CEMC


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