Oncology & Hematology Coding Alert

Why your practice must recommend an appropriate fee

Just because the oncologist administered a form of chemotherapy that has no CPT code, you shouldn't give up on accurate coding to get the pay you deserve. When the oncologist performs this type of service, your only option is to report an unlisted-procedure code. Here's how:

1. Describe the Procedure in Plain English

If you report an unlisted-procedure code (for example, 96549, Unlisted chemotherapy procedure), you should submit a full procedural report to describe the procedure or service. But to get fair reimbursement, the procedure notes alone won't be enough. You should include a separate report that explains in simple, straightforward language exactly what the oncologist performed.

"There's no 'standard' fee for an unlisted-procedure code," says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. "Insurers consider claims on a case-by-case basis and determine payment based on the documentation you provide. Unfortunately, claims reviewers, especially at lower levels, do not have a uniformly high level of medical knowledge, and physicians don't always dictate the most accessible notes."

Submit Great Documentation, Collect Great Pay

The oncology coder should act as an intermediary between the oncologist and the claims reviewer, providing a description of the procedure in layman's terms.

"If the person making the payment decision can't understand what the physician did, there's not much chance that the reimbursement you receive will properly reflect the effort involved," says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Brick, N.J. Be careful to avoid or explain medical jargon and difficult terminology. And, if appropriate, you may include diagrams or photographs to better help the insurer understand the procedure.

For example, under Medicare's current policies, you may bill for the process of image fusion (that is, positron emission tomography/computed tomography fusion imaging) as a service over and above the charge for the exams from which the physician obtained the fused images. Medicare now has no policy on the coding or reimbursement of fusion imaging, which is the anatomic localization of PET (positron emission tomography) or SPECT (single photon emission computed tomography) studies performed with CT (computed tomography). And no CPT code describes the process of image fusion.

When the radiation oncologist clinically indicates the studies, and if a physician provides separate interpretations, you may report the PET, SPECT, CT and anatomic localization studies separately. You should code the CT study separately from the anatomic localization study only when the physician performs a complete study and demonstrates medical necessity. The American College of Radiology (ACR) recommends using 78999 to represent this image fusion, since CPT includes no specific code to describe the service. To describe the procedure, you should use the oncologist's notes as a guide, stressing the main points of the procedure and why it was necessary.

A sample physician narrative might state: "Image fusion is needed to compensate for soft-tissue and respiratory motion to localize the tumor and to spare healthy tissue. Multi-modality image fusion is useful for combining information from different structural and functional imaging modalities. Data from the CT is recorded at maximum inspiration with the arms above the head, and a PET scan is done while the patient breathes with the arms along the sides. Lungs, diaphragm, and other tissues are relatively positioned from PET/CT data sets acquired within the same time frame requiring advanced algorithms to account for spatial artifacts, such as occur due to respiration and to provide a greater degree of accuracy for precise localization of the malignancy. Individual PET and CT images could not precisely determine if the cancer had metastasized. When the fusion image was scrutinized, it was determined that the cancer had spread outside the lungs, indicating that surgery was no longer a viable option for this patient."
 
2. Compare the Procedure You Performed to a Procedure That Has an Existing Code

Insurers often read your procedure description and compare it to similar, listed procedures to determine payment for unlisted procedures, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.

Example: The radiation oncologist needs to "fuse" images he obtained through different modalities to get a "big picture." In some situations - such as when staff takes a CT scan following surgery for malignant tumor removal or after chemotherapy to reduce tumor volume - relying on CT images alone may miss the correct target volume.

CPT provides no code that accurately describes the fusion procedure; therefore, you must rely on an unlisted-procedure code. When the image fusion requires a significant investment in time or resources (above and beyond the time and effort required for 3-D planning), most experts agree that you may be able to use 77299 (Unlisted procedure, therapeutic radiology clinical treatment planning) for the professional component.

Note: When the radiation oncologist performs fusion imaging of CT with an MRI (magnetic resonance imaging) study, you may want to code the physician's fusion imaging as a medical physics consultation (77370, Special medical radiation physics consultation), according to ACR.

'Next-Closest' Code Isn't Good Enough

Instead of letting the insurer determine the "next-closest" code, you should explicitly reference the nearest equivalent listed procedure in your explanatory note. You should also specifically note how the unlisted procedure differs from the next-closest listed procedure, Sandham says.

Quick tips: Remember the following questions when determining whether the procedures differ: