Oncology & Hematology Coding Alert

Talk isn't cheap when choosing E/M codes

Many insurers pay for palliative therapy based on the belief that alleviating symptoms doesn't take as much work as curative therapy, but your oncologist spends valuable time and energy planning palliative care. Here are three ways to secure reimbursement that accurately reflects your physician's workload.

1. Watch the clock for E/M. If your oncologist doesn't complete all of the requirements for an E/M service, you may still be able to report a high-level code if he spends more than half of the time for counseling and coordinating care, says Linda Gledhill, MHA, senior associate with oncology consulting firm ELM Services Inc., based in Rockville, Md.

Example: -A physician spends 40 minutes with an established patient to determine the palliative care the patient should receive. Thirty minutes of this time is spent counseling and coordinating care,- she says. If the 40 minutes are face-to-face, you may report 99215 (Office or other outpatient visit for the evaluation and management of an established patient ... Physicians typically spend 40 minutes face-to-face with the patient and/or family), Gledhill says.

The oncologist should document the total time he spent with the patient, the time he spent coordinating care, and his recommendations and decisions, she adds.

2. Coordinate to end concurrent billing denials. Palliative care often requires an interdisciplinary team approach, Gledhill says.

Snag: Payers may slap you with denials if the patient sees more than one physician on the same day.

Way out: Report the diagnosis code for the condition each physician treated, rather than the most serious illness. If the medical oncologist sees the patient and refers him to a pulmonologist to evaluate the shortness of breath (786.05, Shortness of breath), be sure the pulmonologist reports that as his primary diagnosis instead of the malignancy, Gledhill says.

3. Divvy up your documentation based on intent. If your payer refuses to pay equal amounts for curative care and palliative care, be sure the oncologist divides his documentation, clarifying whether the treatment is meant to (1) be a cure, (2) prolong or improve quality of life, or (3) alleviate pain or other symptoms.