Oncology & Hematology Coding Alert

Melanoma is a deadly form of skin cancer that was once again thrust into public view when one-time presidential hopeful Sen. John McCain of Arizona was diagnosed with malignant melanoma on his arm (172.6) and temple (172.3). Doctors removed the cancerous tissue and later determined that the disease had not spread to other parts of his body.

McCains case offers a glimpse at how coding for malignant melanoma (172.0-172.9) potentially can span the continuum of physician specialties from a patients primary-care physician to the surgeon who removes the malignant tumor to the oncologist who provides chemotherapy treatment.

Internists, family physicians and dermatologists usually are responsible for care of the patient and billing of services up to the point when chemotherapy treatment is needed. Still, oncology practice coders need to pay careful attention to consultation codes and other evaluation and management (E/M) codes to ensure they are reimbursed fairly for their services.

For melanoma patients, the road generally begins with an internist or family physician who first notices the symptoms, usually abnormalities in the skin such as non-asymmetric skin or discolored moles.

By the time a pathology is confirmed and the patient is referred to an oncologist, he or she likely has been seen by a dermatologist who performed a skin biopsy (11100, biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed [separate procedure]; single lesion and 11101 (each separate/additional lesion [list separately in addition to code for primary procedure]) and a general surgeon or surgical oncologist if the biopsy showed a malignancy.

Once there is a positive pathology, the oncologist is usually called in for a consult, says Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology, an oncology practice in Hookset, N.H.

Oncology practices normally provide level-four (99254) or level-five (99255) consults. To rightfully bill for consults in cases such as malignant melanoma, practices need to ensure they perform and document the three key components required for high-level E/M services history, comprehensive exam and medical decision-making.

Three Key Components for High-level E/M Services

Each of the components should be well documented to aid in the coding and reimbursement process. They should contain the following:

1. History. A detailed history will include:

Family history. Oncologists should document the health status or cause of death of parents, siblings and children, specific diseases related to problems identified in the chief complaint or history of present illness; diseases of family members that may be hereditary.

History of present illness. This generally is provided upon referral. Practitioners need to be sure a chronological description of the patients cancer is present in the record.

Past history. This includes a review of the patients past experiences with illness, injuries and treatment, as well as detailed information about prior major illnesses and injuries, prior surgeries and hospitalizations, current medications, allergies, age-appropriate immunization status and dietary habits.

Social history. Physicians need to document past and current activities, including marital status, current and past employment, drug, alcohol and tobacco use, level of education, sexual history, and other relevant social factors.

System review. Physicians need to take inventory of 14 major body systems to help define the problem, clarify the differential diagnosis, identify needed testing, or serve as a baseline for systems that may be affected by possible management options.

2. Comprehensive Exam. This should include a general multisystem exam or a complete exam of an organ system.

3. Medical Decision-making. This refers to the complexity of establishing a diagnosis or selecting treatment options, or both. CPT 2000 instructs physicians to use the following three areas to help determine the complexity of medical decision-making:

The number of possible diagnoses and/or the number
of management options that must be considered;

The amount and/or complexity of medical records,
diagnostic tests and/or other information that must be
obtained, reviewed and analyzed; and

The risk of significant complications, morbidity,
and/or mortality, as well as co-morbidities associated with the patients presenting problem, the diagnostic procedures and/or the possible management options.

To characterize medical decision-making as highly complex, physicians need to prove two of the following:

extensive number of diagnoses or management
options;

extensive review of data; and

high risk of complications, morbidity or mortality.

When patient care is transferred to the oncologist, he or she will determine the best course of treatment, including chemotherapy. Chemotherapy services given to a patient with malignant melanoma can differ from one patient to the next, says Towle. But oncology practices commonly will bill for chemotherapy administration (96400-96549), chemotherapy drugs (J9000-J9999), office or outpatient visits (99211-99215), and administration of supportive-care drugs (90780-90799) and the drugs themselves.