Oncology & Hematology Coding Alert

Poor documentation can put a medical practice in economic jeopardy. If an oncology practices documentation cannot withstand the scrutiny of auditors, the practice could be faced with having to pay back money, or worse. Sound documentation will provide the best protection against allegations of fraud and abuse.

According to Rita Scichalone, MHSA, RRA, CCS, CCS-P, a coding expert and practice manager for the Chicago-based American Health Information Management Association's coding products and services, if oncology physicians can answer the following questions based on the patients medical records, problems should be minimized:

1. Is the reason for the patient encounter stated? Writing patient seen today is not an acceptable notation in the patient record. If the patient is a new patient, the record should clearly indicate a previous diagnosis from a referring physician, such as breast cancer (174.0-174.9), or the patients initial complaint. Subsequent visits for chemotherapy administration (96400-96549) or follow-up care should also be noted.

2. Are all provided services documented? If a code is checked on the fee slip and the service is not described in the medical record, it could lead to payment denial. An audit of a patients chart should reveal descriptions and notations of the services billed. For example, if a practice bills 96412 (infusion technique, one to 8 hours, each additional hour [list separately in addition to code for primary procedure]), notations should include start and stop times and drugs and supplies used. Another example, says Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett, N.H., can be found in the ordering of laboratory tests. If a physician orders a laboratory test, there must be a supporting diagnosis code. For instance, prothrombin time tests (85610-85611), which measure the bloods ability to clot, with a diagnosis such as phlebitis (451.0-451.9), should be included to show medical necessity.

3. Does the note in the patient record explain why support services, procedures and supplies were provided? When rationale and medical necessity are not provided, the payers may assume that services were performed to enhance revenue, and not for patient care. For oncology practices, showing that the physician is following chemotherapy protocol should provide adequate evidence of medical necessity, including the use of non-chemotherapy drugs and supplies.

4. Is the assessment of the patients condition apparent in the record? Because coverage decisions are based on a need for services dictated by a specific diagnosis or injury, payers need an accurate illustration of the patients condition in the chart. If the patients condition is unclear, the service will be denied. Remember, the person who reviews the record may not have a clinical background, so the condition should be explained to be understood by someone without a medical background.

5. Does the medical record include the care plan? This is where the necessity for follow up and surveillance can be described to support the foundation for the medical necessity and appropriateness for future services, Scichalone says. Just as chemotherapy protocols serve as a record of the patients care plan, it is important for oncology practices to ensure the patient record contains a clear plan for follow-up visits, frequency of visits and screenings, Towle adds.

6. Does the record include documentation of the patients progress and results of treatment? This supports the medical necessity and lays the groundwork for proving the need for continued care. For example, the record should indicate how the patient tolerated chemotherapy treatment, which will later support the use of supportive-care drugs such as ondansetron (J2405) to combat chemotherapy-induced nausea.