Oncology & Hematology Coding Alert

Oncologists are losing money because they improperly code their more-than-routine visits. And, to bill legitimately an E/M higher than 99211, they must also strive for improved documentation that establishes the medical necessity of the more detailed visits, says Dianna Hoffbeck, RN, CCM, HCFE, president of Northshore Medical, a coding and medical billing firm in Atlantic City, N.J. 
Practices generally use 99211 to report "incident to" physician services for patients who visit the office for chemotherapy-related care. Routinely, in this type of visit, a nurse monitors vital signs, performs pump and venous access-device maintenance, and asks questions to help the physician gauge the patient's progress. Often, the patient never sees the physician, so the only appropriate code for this visit is 99211. If the physician has face-to-face contact with the patient, a practice can code the range  99212 to 99215. Choosing codes beyond 99211 requires the coder to determine the level of service based on the three key components of care, or the time the physician spends coordinating care.
 
Use the Three Key Components   To bill higher-level E/M services appropriately, oncology practices must make sure physicians provide and strongly document at least two of the three key components of a patient encounter -- history, exam and medical decision-making. 
History -- The physician should query the patient about health, family and social history and conduct a review of systems. You must have documented background data to bill a higher-level code. For 99212, the oncologist must acquire a problem-focused history; for 99213, an expanded problem-focused history; for 99214, a detailed history; and a comprehensive history for 99215.   Exam -- The CPT requires physicians to address specific body areas or organ systems. Following is a guideline for determining the exam level.
99211, 99212: A limited examination of the affected body area or organ system.
  99213: A limited examination of the affected body area or organ system and other symptomatic or related organ systems.
99214: An extended examination of the affected body area and other symptomatic or related organ systems.
  99215: A general multisystem examination or complete examination of a single organ system, such as the respiratory system.
  Medical decision-making -- Medical decision-making refers to the degree of complexity in establishing a diagnosis or selecting treatment options, or both. CPT 2001 instructs physicians to use the following three areas to help determine the complexity of medical decision-making:   
1. Number of possible diagnoses and/or the number of management options that must be considered.
2. Amount and/or complexity of medical records, diagnostic tests and/or other information that must be obtained, reviewed and analyzed.
3. The risk of significant complications, morbidity, and/or mortality, as well as comorbidities associated with the patient's presenting problem, the diagnostic procedures and/or the [...]