Oncology & Hematology Coding Alert

Medicare paid oncology and hematology practices $88,372,541 for 99213 and $268,913,937 for 99214 in 2006, according to recently released statistics. So it's no wonder auditors are on the lookout for overuse of these office visit codes. Keep your claims in the clear -- without letting a rightful dollar slip by -- with these tips.

CMS recently offered a rundown of the top billed E/M codes for the 2006 Medicare Part B. If your coding differs from the pattern too much, auditors may want to know why.

When you-re choosing the correct E/M code, start by looking at the differences between the CPT descriptors for 99213 and 99214. Both codes are for established patient office or other outpatient visits The difference lies in the key components, the degree of the severity of the patient's presenting problem, and the amount of time the physician typically spends face-to-face with the patient and/or family:

- 99213 -- Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity

- 99214 -- Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity.

Note: For a level-three service such as 99213, a physician typically spends 15 minutes of face-to-face time with the patient, while a level-four service such as 99214 typically includes 25 minutes of face-to-face time.

Keep in mind that you need to be sure that the nature of the presenting problem and medical necessity support properly coding level three or four.

Some insurers put up red flags when a practice only reports 99213 for established patient E/M services, says Michael A. Ferragamo, MD, FACS, physician and professor at State University of New York, Stony Brook. He adds that payers wonder what type of patient care a practice is providing when it never codes anything higher or lower than that.

You should always choose an E/M code based on the physician's documentation; your coding will naturally reflect the physician's range of services. According to Ferragamo, the three most common instances for valid reporting using 99214 are the following:

- an established patient presents with a new problem to the examining physician

- an established patient presents with one chronic (ongoing) or worsening problem and one stable problem

- an established patient presents with three stable chronic or inactive problems/illnesses.

Payers and auditors may view obtaining a higher-level component than medically necessary just to charge a higher-level E/M service as "gaming the system," says Barbara Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

While other E/M codes also contribute significantly to the error rate, analysis indicates continuing problems with 99213 and 99214 in particular.

What you can do: Providers should document the specific procedures performed. But remember that if the oncologist performs a level-five service when medical necessity only demands a level-three, you should report a level-three service.

For more statistics and analysis on the allowed and actual payments for E/M services, you can find a complete breakdown of Medicare utilization for Part B on the CMS Web site at http://www.cms.hhs.gov/MedicareFeeforSvcPartsAB/04_MedicareUtilizationforPartB.asp.

Also, the Comprehensive Error Rate Testing (CERT) program report for 2007 provides information about incorrectly paid charges by specialty. You can find it on the CMS Web site at http://www.cms.hhs.gov/cert/downloads/FY2007OverUtilizedCodes.pdf.