Oncology & Hematology Coding Alert

Tip: Different specialties may introduce exceptions.

Your practice may report for new as well as established patients who see your oncologist in his office. One simple approach is to adopt the three-year rule. However, the inclusion of several other influencing factors like multiple locations, physicians of different specialties practicing in the same location, and non face-to-face services, may complicate the approach. Learn how to simplify reporting for each encounter with new vs. established patient codes.  

3 Year Rule Determines Patient Status

“Generally, you should consider a patient to be established if any physician in your group (or, more precisely, any physician of the same specialty billing under the same group number) has seen that patient for a face-to-face service within the past 36 months,” says Marvel Hammer, RN, CPC, CCS-P, PCS, ASC-PM, CHCO, owner of MJH Consulting in Denver, Co.

For example: A patient complaining of dysuria (pain on voiding) comes to your office. Although it is oncologist A’s first time meeting the patient. Oncologist B, in the same group practice, saw the patient two years ago for a similar complaint. In this case, the patient is established.

Don’t let different locations lead you astray: “If your practice has multiple locations, and a physician in location A sees the patient in January, but a physician in location B sees the patient the following December, the patient is established. The need to create a new chart is inconsequential,” Hammer says.

Non-face-to-face encounters don’t count: A primary-care physician recommends a 60-year-old female see the oncologist regarding her breast lump. During the previous year another oncologist in the same practice interpreted some blood test results for hormonal status for this same patient but did not provide a face-to-face service.

In this case, you can still consider a new patient category when selecting an initial E/M code because no physician within the group practice provided the patient with a face-to-face service within the past three years.

According to section 30.6.7 of the Medicare Claims Processing Manual, “An interpretation of a diagnostic test, reading an X-ray or EKG, etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.”

Exceptions Could Occur for Different Specialties

The new patient rule applies when physicians in the same group practice are also of the same specialty.

In a nutshell:  If your practice is a group practice which also includes other specialties, two physicians of different specialties may see a patient for completely different reasons. This would allow you to report a new patient visit even though these two physicians are in the same group practice and saw the same patient within a three-year period.

Example: The urologist in a large multiple-specialty practice sees a patient in 2017 for change in urinary frequency. In early 2019, the same patient sees your oncologist — who is a member of the same multi-specialty practice as the urologist who earlier treated the patient — for an office E/M service regarding a possible bladder tumor.

Because the urologist and the oncologist (who are obviously of different specialties) saw the patient, you may report the oncologist’s initial visit as a new patient.

Consult Codes Don’t Differentiate

Consult codes, 99241 (Office consultation for a new or established patient, which requires these 3 key components… Typically, 15 minutes are spent face-to-face with the patient and/or family) - 99245 (Office consultation for a new or established patient, which requires these 3 key components……….Typically, 80 minutes are spent face-to-face with the patient and/or family), are still used by many non-Medicare payers. These codes do not differentiate between new and established patients. Therefore, when billing for office consultations for non-Medicare and other payers who still accept the consultation codes, regardless of the patient’s status, you should make your outpatient consult code choice from the 99241-99245 and 99251-99255 ranges.

When reporting either the consult or new patient E/M service, you’ll need to meet requirements of all three key components (history, exam and MDM) to report any given level of service.

Short cut: “In effect, this means whichever key component is the lowest will determine the E/M service level you choose,” Hammer says.

Example: During an office visit with a new patient, the oncologist documents a comprehensive history, a comprehensive exam and MDM of low complexity. In this case, the physician has met the history and exam requirements for 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components…. Typically, 45 minutes are spent face-to-face with the patient and/or family) but only meets the MDM requirement for a 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components… Typically, 30 minutes are spent face-to-face with the patient and/or family) visit. Because the level of the lowest key component determines the E/M service level for new patient office visits, you must choose 99203 in this case.

The American Medical Association (AMA) added text to CPT^® in 2006 to clarify all of the key components (history, exam and MDM) must meet or exceed requirements to qualify for a particular level of service for office, new patient (99201-99205), hospital observation services (99218-99220), initial hospital care (99221-99223), office consultations (99241-99245), initial inpatient consultations (99251-99255) and others.

Alternative example: During an initial inpatient consultation, the oncologist documents a detailed history, a detailed examination and MDM of moderate complexity. Because you have met or exceeded all three categories for a level-three service of this type, report 99253 (Inpatient consultation for a new or established patient ...).

2 of 3 Will Do for Most Established E/M Visits

When reporting most established patient outpatient E/M services (except consults and observation care, which do not distinguish new from established patients), you can assign an E/M level based on just two of the key components, Hammer says.

Example: An established patient is seen for a new complaint. The physician documents a problem-focused history, expanded problem-focused exam, and low-complexity MDM. In this case, the history only meets the level of 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components….. Typically, 10 minutes are spent face-to-face with the patient and/or family), but because the other two components meet the requirements for 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components… Typically, 15 minutes are spent face-to-face with the patient and/or family), you may report the 99213.

Per CPT^®, you must meet or exceed requirements for two of the three key components for established patient office visits (99212-99215), subsequent hospital care (99231-99233), subsequent nursing facility care (99307-99310) and others.

Consider: “Medicare contends medical necessity to be the overarching criterion for E/M level selection. Therefore, while medical decision-making (“MDM”) is often the most important element and is closely related to medical necessity, it is not completely synonymous,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Associate Partner, Pinnacle Enterprise Risk Consulting Services, LLC. “Therefore, when “MDM” does not meet the level of the performed and documented history and examination, you do not have to automatically “down-code” the service to the level of the MDM. Consider the nature of the presenting problem, and need for a higher level of history and exam to evaluate whether the E/M level can accurately support the level using the other two components. If those are justified, the higher code may apply. If not, the code supporting MDM is the most appropriate choice.”

Watch for Overcoding

Generally, medical necessity should determine the MDM level and, ultimately, the appropriate E/M service level. Physicians should not, for instance, report a comprehensive history and examination at every visit and expect to report 99215, regardless of the documented level of MDM.

Simply stated: If the presenting problem does not support a high-level E/M service, you should not be paid for a high level of care just because the physician documented a comprehensive history and examination.

Also, remember Medicare and many private and commercial payers follow the 2010 change in Medicare policy eliminating the use of the consultation codes. For these payers, office consultations are billed with 99201-99205 (Initial new patient ...) and/or 99211-99215. Inpatient consultations are billed with 99221-99223 (Initial hospital care ...) and/or 99231-99233 (Subsequent hospital care ...). In contrast to the above coding, for these consultation visits, you must distinguish between new and established patients beforehand and code accordingly to the status of the patient, new or old.

A final note: You may report E/M services based on time — rather than the key components of history, exam and MDM — if your oncologist spends more than 50 percent of the total visit time counseling and/or coordinating care. “Remember, documentation of the total time, time spent counseling /coordinating care (must be greater than 50% of total visit) and a description of the content is also required,” says Jodi Nayoski, CPC, CCS-P, CHC,CDIP, Director, Pinnacle Enterprise Risk Consulting Services, LLC.