Oncology & Hematology Coding Alert

Experts clarify Medicare guidelines

If you want to get your oncologist paid for E/M services and minor surgical procedures he performs in a teaching setting, you should know Medicare's documentation and supervision requirements for the teaching physician rules, coding experts say.
 
When your oncologist works as a "teaching physician" (TP) and supervises a resident's services in an office or hospital setting, you will have to report your physician's work using the teaching physician rules, according to the Medicare Carriers Manual (MCM), section 15016.
 
The MCM defines residents as an intern or fellow who's enrolled in an accredited graduate medical education (GME) program, says Marti Geron, CPC, CMA, CM, coding and reimbursement manager at the University of Texas Southwestern Medical Center at Dallas. To appropriately report services under the teaching physician rules, make sure your resident meets Medicare's definition.
 
Experts offer four field-tested strategies for reporting E/M services and minor surgical procedures using the teaching physician rules.

1. Report Office Consults Based on 'Key Portions'

You can report E/M codes if the TP personally furnishes the E/M service, such as an office consultation (99241-99245), without the resident present, said Jillian H. Kuruc, MHA, CPC, CCS-P, a clinical technical editor with Ingenix Health Intelligence in Binghamton, N.Y., during a session on the teaching physician rules at the Third Annual Coding, Billing, and Compliance Essentials Conference in Orlando, Fla.
 
If the resident also performed this E/M service, your oncologist would have to duplicate the "critical and key portions" of the resident's services to bill under this guideline, Kuruc tells Oncology Coding Alert. The TP should define - and be able to defend - those critical and key portions, she adds.
 
For example, a primary-care physician (PCP) requests an opinion on a patient with enlarged lymph nodes. The TP considers the lymph node exam a critical portion of the patient evaluation. The resident evaluates the patient, and
based on the findings, diagnoses the patient with chronic lymphadenitis (289.1) and recommends a treatment plan. The resident bills the visit as 99243 (Office consultation for a new or established patient ...).
 
The TP also evaluates the patient's lymph nodes, performs a detailed history and physical exam, and discusses possible treatment options with the patient. But Medicare requires that the attending physician only document that he or she performed the office visit's critical portion, and that the physician directly cared for the patient.
 
The TP doesn't have to duplicate the resident's progress notes, but should refer to the resident's notes and state that the TP reviewed the resident's medical documentation and agrees with the diagnosis, Geron says.
 
If the resident did not attend the oncologist's evaluation of the patient, and also didn't perform a complete E/M service, your physician must bill and document the office visit as he would in a non-teaching setting, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.
 
In other words, to support a 99243 claim, the oncologist would have to document a detailed history, a detailed examination, and low-complexity medical decision-making.

2. Document Physician Presence for Critical Care

The oncologist can also perform an E/M service jointly with the resident, Kuruc says. Suppose a patient develops a fever (780.6), respiratory distress (786.09), and low blood pressure (458.x) during chemotherapy. The TP treats the patient with antibiotics and intravenous fluids, and the resident evaluates the patient's condition. Later, the TP admits the patient to the critical care unit for septic shock (785.52). Overall, the physician and the resident treated the patient for 35 minutes.
 
In this case, your physician may be able to report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient ...), as long as the documentation supports the code.
 
The TP should document that the critical care time doesn't include the injection and that he treated the patient jointly with the resident. Also, the TP should note that he  directly supervised the resident for the full 35 minutes of treatment, directly managed the patient's care and reference the resident's note, Pohlig says.

3. Supervision Is Key to Reporting Minor Surgeries

When you report minor surgeries and endoscopic procedures, you should make sure the physician documents that he directly supervised the entire procedure, Kuruc says.
 
That means Medicare requires the physician's presence in the room. For example, your physician can't view the surgery through a monitor in another room, Pohlig says.
 
Suppose a PCP requests that your oncology practice biopsy a possibly cancerous growth on a patient's colon. Your oncologist supervises the resident during a lower gastrointestinal endoscopy (45331, Sigmoidoscopy, flexible; with biopsy, single or multiple) to detect the potential cancer.
 
To get your oncologist paid for the 45331, the oncologist would have to remain in the operating room from the scope insertion to the scope's removal.

4. Don't Worry About the Primary-Care Exception

The MCM allows a TP to get paid when a resident provides an E/M service without directly supervising the visit under the primary-care exception.
 
But this primary-care exception refers to E/M new patient codes 99201-99203 and to established patient codes 99211-99213, the MCM states.
 
And, the primary-care exception applies only to primary-care offices, such as internal medicine, family and pediatric practices, Kuruc says. Most oncologists don't serve as primary-care physicians, so you shouldn't try to report E/M codes under the primary-care exception.