Oncology & Hematology Coding Alert

Tip: Check the three-year rule for established patients.

Your practice probably reports E/M codes more than any other service, but knowing whether you're reporting these codes correctly is paramount to collecting. However, that doesn't mean you never have questions about how to report these services. Read on to check out six of the most frequently-asked questions on these commonly-billed codes.

Follow the Three-Year Rule for 'Established' Patient

Question 1:  Our physician evaluated a patient in the hospital. The patient, who in the past was treated for breast cancer, was now admitted for dizziness. Our physician did the evaluation for 2 consecutive days before the patient was discharged. Following a week after discharge, the patient presented to the physician's office for a follow up evaluation. How can we report the office-based visit? Will this patient be considered an established patient?

Answer 1: Yes. Because your physician provided face-to face-services in the hospital, the patient would be considered established in the office even though it is the patient's "first" visit to the office. For the office visit, you would choose from the codes for established patients, 99212 (Office or other outpatient visitfor the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making...) - 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity...).

Follow this rule: You have to keep the "three-year rule" in mind for new patients. CPT^® says that a new patient is one who has not received anyprofessionalface-to-face services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

Does E/M Format Matter?

Question 2: Our physician reported established patient office visit code 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: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity...), but does not have documentation for a standard progress note. The only note in the chart is a letter back to the referring doctor detailing the patient's condition. Can we bill this claim without using the standard progress note?

Answer 2: Yes, you can bill the claim without a standard progress note. The format of a standard E/M progress note is typically recommended, but not technically required by insurers, so a letter could be allowable, depending on what information you can find in that letter. Is there a chief complaint, review of systems, medication reconciliation, physical examination, and other similar documentation supporting the assessment and plan of care in the letter that supports 99213? If so, then it should hold up as documentation of the patient's visit.

New Patient Rules Are Tricky

Question 3: We found several instances where our physician saw a new patient but didn't document the minimum levels of history required (he either documented no chief complaint or no HPI) to bill any new patient office visit codes (99201-99205). What can we report in circumstances like this?

Answer 3: Unfortunately, you can't report a new patient code without a history. Review the brief History of Present Illness (HPI) information the physician documented to determine if the statement contains both elements of a CC (chief complaint) and HPI. The doctor must document the HPI, exam (with the exception being vitals, which an ancillary staff member can document), and the Medical Decision Making (MDM). You need documentation of all three key components (history, exam, and MDM) to support even the lowest new patient level E/M code.

If you truly have no HPI documentation, you cannot submit a claim with the new patient E/M codes (99201-99205). Help educate your providers on the importance of clear E/M documentation. The HPI is a vital part of the patient record that documents the reason why the patient is seeking care and the circumstances surrounding the clinical presentation leading up to and including the present. If a physician routinely omits the HPI, it may be difficult to establish medical necessity for some patient encounters.

Exception:  The initial visit can be coded based on time if more than 50 percent of the face to face visit is spent counselling or coordinating care, and it's documented in the medical record.

Can You Rely on EMR Codes?

Question 4: Our oncologist meticulously maintains documentation. Because he documents in the electronic health record so well, almost all of his cases qualify for a 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity...) or a 99215. Since the documentation supports his code selections, is this acceptable?

Answer: 4: Not necessarily. Providers in oncology often do detailed history taking and more extensive examinations routinely. Your electronic health record will most likely offer an E/M code suggestion at the end of each visit - but that doesn't mean you can use that to justify all high-level codes.

Several practices have told Oncology Coding Alert that their physicians "thoroughly document" the History and Physical Exam elements for all conditions, leading to high-level codes, even if the Medical Decision Making (MDM) doesn't support 99214 or 99215. They justify this by pointing out that established patient office visits only require two out of three criteria (History, Exam, MDM). However...

Face the truth: You must have medical necessity to report high-level codes - you can't simply perform the requirements of these codes to drive a higher E/M level routinely. "Look to the nature of the presenting problem to help navigate to the most appropriate code. It may also be wise to seek advice from a clinician to help steer you to where the level should be," says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Managing Director of Pinnacle Enterprise Risk Consulting Services ("PERCS"), a division of Pinnacle Healthcare Consulting.

Vitals aren't an Imperative

Question 5: Our oncologist examined a patient with persistent hoarse voice and did not obtain the vitals. He documented the office visit for this "no appointment add-on" service, but our office manager said that we cannot bill for the encounter since no one took vitals. He did document everything else (history, exam, medical decision making). Is the office manager right?

Answer 5: Although they are almost always documented, vitals are not required in order to bill an E/M visit. Vitals are important - and usually the norm- but they are really are just another component of the exam performed. Since the physician documented the history, exam, and level of medical decision making, he should have sufficient notes for the practice to choose the correct E/M code.

Don't Jump to Report E/M Codes

Question 6: Our nurse gave a patient an allergy shot. Which E/M code can we report with it? The nurse circled 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) but we aren't sure if it's applicable here.

Answer 6: You can't bill 99211 for just an allergy shot or vaccination. For allergy shots, you should code 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) for a single shot or 95117 (...2 or more injections) for two or more shots.

If the billing provider supplies the allergy serum, then you should bill for the serum at the time the provider makes the new serum. For vaccinations, bill the vaccine separately and use 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]) for a single injection, 90473 (Immunization administration by intranasal or oral route; 1 vaccine [single or combination vaccine/toxoid]) for a single nasal/oral vaccination, or +90472 (...each additional vaccine [single or combination vaccine/toxoid] [List separately in addition to code for primary procedure]) for each additional vaccination that is IM, subcutaneous or intradermal. If giving an IM and Oral vaccine at the same time use the each additional oral vaccine code 90474 (Immunization administration by intranasal or oral route; each additional vaccine [single or combination vaccine/toxoid] [List separately in addition to code for primary procedure]) instead of the 90473.

Note: If the nurse provides a separate, medically necessary E/M service - for example, if the patient has a separate illness or a reaction to the injection that requires a separate evaluation - then you can separately bill for these services using 99211 with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended when the documentation supports it.