Oncology & Hematology Coding Alert

There's no time like the present to hone your E/M coding skills. Read on to sharpen your coding senses to a fine point using the answers to three important E/M questions submitted by our readers

Question: Dr. Jones admits a patient to the hospital, and three days later the patient is ready to be discharged, but Dr. Jones isn't available. My understanding is that Medicare allows only the admitting physician to bill a discharge for the patient. So in this situation, how can we get paid for the discharge (99238-99239) since a different member of our practice performed it?

Answer: Go ahead and bill that discharge.

Because the physicians are all members of the same group, any of them can perform the discharge, says Suzan Berman-Hvizdash, CPC, CPC-EMS, CPC-EDS, physician educator with UPMC in Pittsburgh.

Take note: This recommendation appears in the Medicare Claims Processing Manual, advising that "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician." You can find more information on the CMS Web site at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.

Question: If an oncologist visits a patient in the hospice and performs a consult, does the physician report a normal consult code (such as 99241) or does he report G0337?

Answer: In this situation, G0337 (Hospice evaluation and counseling services, pre-election) is probably not the correct code "because this evaluation is to determine if the patient would like to be placed in hospice," says Kevin Solinsky, CPC, CPC-I, CPC-ED, with Healthcare Coding Consultants LLC in Gilbert, Ariz. Code G0337 specifically says, "hospice evaluation and counseling services, pre-election," which means you should bill it before the patient decides to enter into a hospice program, Solinsky says.

In addition, always remember the "three R-s" of billing consults, even in the hospice setting. You need to document "the consult request, rendering of the consult, and replying back to the requesting provider in writing," Solinsky says.

If the visit didn't meet CPT's or the payer's definition of consult, this was most likely a new or established patient visit. If this is the case, you should bill it with the appropriate office/outpatient code, such as 99201-99215, Office or other outpatient visit.

Question: When I-m coding a high-level E/M for an established patient, I can usually meet the requirement for either history or examination. What else do I need to do to submit the E/M correctly?

Answer: For established patient E/M codes 99214-99215, you need to meet the appropriate level for at least two of three requirements: history, examination and medical decision-making.

Translation: When you meet the history or examination requirement for 99214 (Office or outpatient visit for the evaluation and management of an established patient ... medical decision-making of moderate complexity ...) or 99215 (... medical decision-making of high complexity ...) you-ll still have to choose a code based on MDM. To do this you need to take several considerations into account because you have more than one MDM level to choose from.

Best bet: You-ll find both the 1995 and 1997 E/M Documentation Guidelines in the E/M guidelines in your CPT manual. You can also access these through the CMS Web site at http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp. These guidelines detail the exact requirements for MDM.

In short, you need to meet or exceed two of the three elements for a level to choose that MDM level. According to CMS, medical decision-making "refers to the complexity of establishing a diagnosis and/or selecting a management option."

You can determine this by considering each of the following factors:

- 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

- the risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient's presenting problem(s), the diagnostic procedure(s), and/or the possible management options.

If your oncologist documents multiple management options and moderate risk of complication, but only a limited amount of data to be reviewed, you meet two of the three requirements for moderate MDM, which is sufficient.

Example: An ambulatory, established metastatic colon cancer patient with increasing fatigue arrives for his weekly 5FU therapy office visit.

The oncologist documents that the patient's cancer is stable or improving, while his fatigue is getting worse. This qualifies as multiple diagnoses.

Check the table of risk in either the 1995 or 1997 E/M Documentation Guidelines to determine that the risk of complication is high.

Multiple diagnoses, no tests ordered or reviewed, and high risk suggest that this encounter qualifies as moderate MDM. You need to meet or exceed two of three requirements, so you eliminate the lowest, amount of data, which falls under minimal MDM.

High risk falls under high complexity, but multiple diagnoses only meets the moderate-complexity category, so you have to choose moderate complexity.

Don't forget: Report the fatigue with its own diagnosis code (such as 780.79, Other malaise and fatigue), along with any other side effects or symptoms.

Here's why: If the oncologist is treating multiple conditions, you should report multiple diagnosis codes -- just be sure the oncologist documents the conditions in the medical record.