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 possible management options.

 

Make the Distinction -- 99211, 99212 and 99213  
 
The elements of an office visit for 99211 and 99212 are virtually the same. However, for 99212, in addition to the exam, which would be similar to 99211, the physician  might examine the site of the cancer and review how the treatment is progressing. Very little or no medical decision-making would be involved, other than to continue with the current treatment plan. 

The rationale for using 99213 rather than 99211 or 99212 is similar. Again, physician presence is the key element. Code 99213 represents slightly more extensive physician services that might include examining more than the disease site, perhaps checking for side effects of the treatment. For example, a patient might complain of bouts of nausea and headache following treatment. The physician conducts an exam that focuses on the complaint and prescribes medication to deal with the side effects -- fulfilling the expanded problem-focused exam and low- complexity decision-making requirement of 99213.

 

 

Documentation must support medical necessity for using the higher codes. Medicare recognizes the need for chemotherapy-related visits in which the physician is present. And, most cancer treatments follow protocols that elaborate on how often a patient should be seen during treatment, as well as the normal course of treatment, Hoffbeck says. Because of these treatment protocols, it's easier to document medical necessity more accurately, says Imelda Lee, RHIA, CTR, coding supervisor for University of Texas Health Science Center's University Physicians Group in San Antonio.

 

For coders, the medical record is still the most important piece of documentation. They should look at the notations in the patient's record for the presence of the physician in the exam room and a description of the encounter that must include, at minimum, the site examined and any medical decisions.

 

 

Sometimes visits do not fall into a neatly packaged category. For example, a patient comes in for a follow-up visit after a recent round of chemotherapy and stays for 30 minutes, half of which the physician spends asking questions to determine the patient's progress and the severity of side effects. No history is taken and the only medical decision is to continue the current plan of care. But, the other 15 minutes is spent answering questions, reviewing the plan of care, and reassuring the patient.

 

"If coordination of care is more than 50 percent of the visit and the physician documents the time spent with the patient, then the practice has the right to bill for a 99213," Lee says. According to Hoffbeck, medical necessity is also on the side of the physician when using time as the determining factor for a higher-level visit. Payers, including Medicare, recognize that the very nature of the diseases medical oncologists treat calls for increased face-to-face contact between patients and physicians. Oncologists should reject the notion that routine or normal visits are nurse-only and that physician presence signifies  something abnormal.  

 

Hoffbeck and Lee agree that a visit spent mostly on coordination of care in which significant time is spent talking with the patient or patient's family should be reported as 99213. These conversations last longer than 15 minutes, which the CPT describes as the typical time spent face-to-face with the patient.

 

The level of coding for a routine chemotherapy visit is limited. In most cases, 99212 or 99213 are the most appropriate because they reflect the services normally provided. Hoffbeck and Lee warn that 99214 and 99215 should be reserved for visits that require complex care or medical decision-making.

 

For example, during a routine chemotherapy follow-up visit, the physician discovers a new illness. The oncologist has to reconsider the patient's current plan of care, which involves a detailed or comprehensive exam and moderate or complex medical decision-making. This naturally raises the level of the visit beyond 99213.

 

With cancer patients, anything can happen during an office visit, so limiting the level of the visits you bill can be costly. "There is no normal chemotherapy visit," Hoffbeck says. "Patients are not only dealing with the disease but usually are suffering from nausea or insomnia, or just fearing for their lives. They need physician time and attention and want to be reassured."