Oncology & Hematology Coding Alert

Master CMS- long list of project G codes and earn an extra $23 per encounter

Oncology practices are buzzing about the 81 new codes associated with the 2006 demonstration project. CMS wants to track the quality and spectrum of cancer care, but you-ve got to learn how to code properly for the project to make it a success. Here's how to incorporate this project into your daily coding routine with ease.

The lowdown: CMS wants you to report G codes representing the focus of the visit, the relation of the treatment to current guidelines, and the disease status for particular cancer patients.

CMS- objective for the voluntary 2006 demonstration project is to base oncology payments on patient-centered care rather than chemotherapy administration, which may not require much doctor/patient interaction. CMS wants to look at the quality and spectrum of care patients receive and determine whether it represents best practice.

The project is open to oncology patients based on diagnosis, unlike the 2005 project, which focused on type of treatment, says Linda Gledhill, MHA, senior associate with oncology consulting firm ELM Services Inc., based in Rockville, Md. For the 2005 project, you reported codes representing chemotherapy patients- analysis of certain symptoms--nausea/vomiting, pain and fatigue.

Pinpoint Suitable 2006 Project Patients

The criteria: You may self-enroll in the project simply by reporting the appropriate G codes on a patient's claim. Just be sure you meet the following guidelines, according to the CMS release -2006 Oncology Demonstration Program: Improved Quality of Care for Cancer Patients Through More Effective Payments and Evidence-Based Care- (available at www.cms.hhs.gov/apps/media/press/release.asp?Counter=1717).

Here are the rules you need to know:
 
- Report the appropriate demonstration project G codes only for an office-based hematologist or oncologist.

- Use the G codes only when the physician provides an E/M service (levels 2-5) to an established patient; you should report the G codes in conjunction with the E/M code.

- Be certain that the established patient's primary diagnosis meets one of 13 major diagnostic categories:

- cancer of the breast (female; invasive)
- colon
- rectum 
- prostate
- lung (both small cell and non-small cell)
- stomach
- esophagus
- pancreas
- ovary
- head and neck
- chronic myelogenous leukemia
- multiple myeloma
- non-Hodgkin's lymphoma.

Report the Right G Code for Each Range
 
If you meet the above criteria, you then have to choose the appropriate G codes for your patient. The list can be quite imposing, Gledhill says.

Here's a breakdown of the code ranges you need to know:

- G9050-G9055 (Oncology; primary focus of visit ...). These codes are differentiated based on whether the oncologist provides a workup at the time of diagnosis, decision-making after staging, disease surveillance after therapy, management of a patient with cancer that isn't being treated, palliative care, or an unspecified service.

- G9056-G9062 (Oncology; practice guidelines ...). Codes G9056-G9062 differ based on whether the physician adheres to guidelines or differs from them because the patient is in a clinical trial, the physician disagrees with available guidelines, the patient chooses an alternative, the patient's comorbidity isn't factored into current guidelines, no available guidelines cover the condition, or for other reasons not listed.

- G9063-G9130 (Oncology; disease status ...). In these codes, you-ll find ranges to report the disease status for the primary diagnostic categories listed above.

The CMS HCPCS file lists these codes with a -C- under coverage, meaning payment is determined by the carrier, but CMS announced that providers can expect $23 per encounter (in addition to the E/M fee) if you report a code for each of the three criteria.

Note: You can find the full list of HCPCS codes at www.cms.hhs.gov/HCPCSReleaseCodeSets/. You can also download recent updates from this site.

Keep Project Documentation Under Control

Problem: When it comes to keeping track of demonstration project documentation, keeping -loose forms attached to the superbill is a nightmare,- says Sarah Taylor, reimbursement services director for Purchase Cancer Group, which has offices in Kentucky and Tennessee.

Loose forms result in too much paperwork and are -lost revenue waiting to happen,- she says.

Solution: To collect the required documentation this year, Taylor's working with her IT department manager on programming a form in their electronic health records (EHR). Benefit: Physicians and mid-level practitioners can fill out the form as part of their E/M work flow processes, Taylor says.

Remember to Report All the Project Components

Example: Your office-based oncologist provides an E/M service for an established patient. The service takes 25 minutes and includes a detailed examination and medical decision-making of moderate complexity. The oncologist documents that the primary focus of the visit was treatment decision-making after he restaged the cancer and he will be adhering to practice guidelines. The documentation also shows that the patient has progressive esophageal cancer.

What to do: Check your documentation to be sure your record matches your code descriptors. If so, then report the following:

E/M: Report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: a detailed history; a detailed examination; medical decision- making of moderate complexity ...). Why: The physician provided an E/M, including a detailed exam and medical decision-making of moderate complexity, for an established patient.

Primary focus: Choose G9051 (Oncology; primary focus of visit; treatment decision-making after disease is staged or restaged, discussion of treatment options, supervising/coordinating active cancer directed therapy or managing consequences of cancer directed therapy [for use in a Medicare-approved demonstration project]). Why: The documentation shows treatment decision-making as the primary focus of the visit, which took place after the physician restaged the cancer.

Practice guidelines: The proper code to report is G9056 (Oncology; practice guidelines; management adheres to guidelines [for use in a Medicare-approved demonstration project]). Why: The physician reported that he would adhere to practice guidelines.

Disease status: Code the disease status in this case with G9098 (Oncology; disease status; esophageal cancer, limited to adenocarcinoma or squamous cell carcinoma as predominant cell type; M1 at diagnosis, metastatic, locally recurrent, or progressive [for use in a Medicare-approved demonstration project]). Why: The patient has progressive esophageal cancer.

Caution: Before reporting any of the above codes, verify that your documentation meets the requirements for the full descriptor of that specific code.

Diagnosis: Remember, to qualify for the project, your patient's primary cancer diagnosis must be one of the 13 designated by CMS. Check your documentation, then report the appropriate code, such as 150.0 (Malignant neoplasm of esophagus; cervical esophagus).