Oncology & Hematology Coding Alert

Detailed questioning is crucial to correctly coding for evaluation and management (E/M) services because the amount of documentation done drives reimbursement.

Therefore, oncology practices should treat patient charting as an ally to secure the highest levels of reimbursement for E/M services (99201-99215), advises Cathy Klein, LPN, CPC, senior consultant with Indianapolis-based Health Care Economics, Inc. If its not documented, it didnt happen, Klein warns.

Patients need to be closely questioned during their initial visits about:

1. Family history. This includes 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.

2. History of present illness. While this may be provided upon referral, practitioners need to be sure a chronological description of the patients cancer is in the record.

3. Past history. The chart should include a review of the patients past illness, injuries and treatment. Detailed information about prior major illnesses and injuries; prior surgeries and hospitalizations; current medications; allergies, age appropriate immunization status and dietary habits.

4. 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.

5. System review. Physicians need to take inventory of 10 major body systems or pertinent systems to help define the problem, clarify the differential diagnosis, identify needed testing, or serve as a baseline for systems that might be affected by possible management options. A statement such as all other systems reviewed can be substituted for those systems that have negative findings.

New Patient, New Problem, Four Questions

I always recommend to physicians that they have a well-documented history of the present illness (HPI) when seeing a new patient or addressing a new problem, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in North Augusta, S.C. She recommends asking these four questions at the minimum:

1. How long have you had the problem?
2. How has it changed during the course of that time?
3. What are your signs and symptoms?
4. Has anything been tried so far? If so, what was the outcome?

Callaway-Stradley says documenting the answers to these questions in conjunction with the past, family and social history, and the review of systems, should provide enough history to support any level of service.

Its key that there be background data in order to bill, Klein says. The basic format for E/M services recognizes seven components, six of which are used in defining the levels of E/M services, according to Alan Ertle, MD, MPH, The Corvallis Clinic, P.C., in Corvallis, Ore. The [...]