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Oncology & Hematology Coding Alert

Conflict of Opinion:

99211 and Chemo Administration:Separate Services?

Published on Wed May 01, 2002

In the second-quarter issue of Florida Medicare B Update, which came out in February 2002, oncology practices were scolded by the state's Medicare medical director, Sidney R. Sewell, MD, who singled out billing of 99211 (Office or other outpatient visit) with chemotherapy services as a key contributor to the state's higher-than-average billing of the level-one office visit code.

Sewell said that if Florida providers billed CPT 99211 at the same rate as the national average, Florida Medicare would save more than $10 million a year. Specifically, Sewell was concerned with chemotherapy-related office visits that oncology practices were billing as "incident to" visits that included inserting a catheter, setting up an IV, monitoring for adverse reactions, and dealing with nausea. None of these, he wrote, satisfies requirements that would deem 99211 as a "significant and separately identifiable" service. For oncology practices to appropriately separate 99211 as incident to physician services, there must be a problem outside of preparing for scheduled chemotherapy treatment that requires medical decision-making.

In addition, Sewell said the phrase "may not require the presence of a physician" in the CPT descriptor for 99211 causes doctors to mistakenly assume that they do not have to be in the office suite to bill for "nurse-only" visits. He urged Medicare providers to review the details of billing 99211 to reduce payment errors.

Sewell says his views do not represent a new policy for Florida Medicare providers to follow, nor does it mean that a mass review of claims is under way or being planned.

While his comments are directed toward Florida practices, oncology in particular, it is not unreasonable to assume that medical directors and Medicare carriers around the country share his view.

ASCO Argues for 99211

Coding experts agree with Sewell that physician presence in the office suite is required to bill 99211. However, some believe that 99211 should be used to report services related to the chemotherapy visit.

"As long as the nurse takes good notes, including recording any complaints and an assessment of the patient's condition not just the fact that the patient was hooked up for an infusion 99211 is appropriate, and practices should be able to bill it," says Dianna Hofbeck, president of Northshore Medical, a coding consulting and billing firm in Atlantic City, N.J.

Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hookset, agrees with Hofbeck. "Any knowledgeable nurse will conduct an assessment of the patient prior to chemotherapy administration to check for toxic side effects from previous chemotherapy treatment," Towle says. "This assessment, as long as it is thoroughly documented, should be enough to bill 99211."

The American Society of Clinical Oncology's (ASCO's) Practice Tips for the Practicing Oncologist also indicates that 99211 is an appropriate code to use with chemotherapy administration as long as the physician is involved in the treatment management. There is no mention of the need for a new problem to be present to separate the level-one visit from the chemotherapy administration.

Sewell's comments prompted ASCO to respond. In a March 8, 2002, letter, Joseph S. Bailes, MD, chief public policy liaison for ASCO, and Michael B. Troner, MD, chairman of ASCO's clinical practice committee, wrote: "There is no basis for adding any further requirement that the physician's involvement be 'significant' and 'separately identifiable,' as your update does."

ASCO disagrees with Sewell on the following points:

  • His interpretation that the standard for billing 99211 with chemotherapy is that there be a "significant, separately identifiable" E/M service.
  • The type of physician involvement necessary to bill 99211 in a manner that is inconsistent with national Medicare policy.
  • His indication that 99211 must be billed with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) even when billed in association with chemotherapy.

    Note: Sewell denies making the third point and believes ASCO mistakenly attributed this point, which appeared elsewhere in the publication.

    According to ASCO, on days when a patient receives chemotherapy and the physician has no face-to-face contact with the patient, the oncologist may report and be paid for incident to services furnished by employees of the physician in addition to the chemotherapy administration.

    For example, a patient presents for chemotherapy, and a nurse performs an exam focusing on the patient's reaction to previous treatment. The nurse documents the findings in the record, including reporting the findings to the physician with his or her recommendations. In this instance, 99211 is appropriate, Hofbeck says. After the completion of the E/M services, the nurse administers the chemotherapy via infusion technique. The entire encounter should be coded as follows:

  • 96410 (... infusion technique, up to one hour)
  • J9000 (Doxorubicin HCl 10 mg)
  • 99211
  • J2405 (Injection, ondansetron HCl per 1 mg)
  • 90780 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) if the therapy was administered sequentially to chemotherapy administration.

    Follow Incident To Guidelines

    If a chemotherapy-related visit is a "nurse-only" visit checking vital signs, evaluating the patient's current health status, explaining upcoming treatment, and preparing the patient for chemotherapy the oncology practice is allowed to bill 99211 as incident to a physician's services. You must, however, follow incident to guidelines:

  • A physician who is a member of the oncology practice, but not necessarily the patient's physician, must be present in the office at the time the midlevel provider administers the chemotherapy.
  • The nurse must be employed by the oncology practice.
  • The procedure must be an expense to the practice.

    According to Medicare guidelines, incident to physician's services means that the services or supplies are furnished as an integral, although incidental part of the physician's personal professional services in the diagnosis or treatment of an injury or illness. According to Medicare guidelines, these services are commonly furnished in the physician's office.

    Solidify with Documentation

    In 1998, CMS showed concern that too many oncology-audited claims of level-one visits lacked supporting documentation in the medical records. With poor documentation, auditors were left with little choice other than to reject claims. The key to documentation is to show physician involvement despite the absence of face-to-face physician time. Documentation of physician involvement can be made in the physician's progress notes, the nurse's notes, the flow sheet, or on other appropriate forms contained in the medical record.

    ASCO offers examples of adequate documentation in a nurse's notes:

  • "Dr. X reviewed counts and decided to continue chemotherapy."
  • "Patient afebrile. Dr. X said to continue chemotherapy."
  • "Discussed patient's nausea with Dr. X."

    According to ASCO, these notations bolster the impression that the physician was involved in the management of the patient's chemotherapy treatment.

    There is still room for abuse of 99211, most of it centered on using the code to report minimal problems that may not require the presence of a physician. For example, if only an injection is given, oncology practices cannot bill 99211 without some evidence that the nurse asked the patient questions regarding his or her illness, or gave instructions regarding care. In addition, 99211 cannot be used for:

  • telephone calls
  • venipunctures
  • prescription renewals to a pharmacy
  • rescheduling an appointment
  • calls to give lab results.

    Sewell is not acknowledging that his column sparked significant response. He also does not rule out the possibility that he misinterpreted Medicare policy.

    "Since I wrote this, I have received letters from oncology practices," Sewell says. "I do not want to be guilty of not evaluating Medicare policy correctly. I will ask CMS for clarification."

    Experts advise practices to continue billing 99211 with chemotherapy administration codes when appropriate. However, practices in Florida should follow the direction of their Medicare carrier for the time being, says Rise Cleland, president of Oplinc Oncology Services, an oncology coding consulting firm in Lawton, Okla. While some may disagree with Sewell's interpretation, he represents carrier policy, which determines payment.

     

     

     

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