Oncology & Hematology Coding Alert

Keep the same focus on common sense and compliance that you use for paper records.

Electronic medical records (EMRs) offer a number of benefits to oncology practices. They save time, create documentation that is thorough and legible, and make it easier to share health history with fellow providers. But the flipside is that practices can rely too heavily on EMRs when it comes to determining what needs to be documented and which code to use.

Consider these three EMR myths, all of which are based on questions submitted to The Coding Institute (TCI), to show you exactly where your EMR system could be leading you astray.

Myth 1: Exam Documentation Carries Over

If your EMR consistently shows E/M documentation that is robust in one section (such as History) and thin in another (such as Exam), you may be trusting your software programming to do too much.

A subscriber recently told TCI that an auditor downcoded many of her E/M claims due to empty “Physical Exam” sections in the documentation. The practice argued the EMR vendor had told them that patients being seen for established problems already have exam documentation on file and that the EMR will carry it over from one visit to the next.

Reality: Carrying information over for follow-ups is allowed to some degree for past medical, family, and social history (PMFSH), but not for an exam.

E/M guidelines state that if a patient’s PMFSH has not changed since a prior visit, your provider doesn’t have to redocument the information. He does, however, need to document that he reviewed the previous information to be sure it’s up to date and note in the present encounter’s documentation the date and location of the initial earlier acquisition of the PMFSH. Many payers will give no PMFSH credit if you overlook one of these criteria. To meet the rules, the provider could say, “I reviewed the past, family, social history with the patient taken from today’s patient questionnaire and our previous visit of Jan. 15, 2013. She reports that nothing has changed since that date.”

In contrast, if your E/M code depends on the level of exam, there is no substitute for recording physical exam information at each visit.

Providers shouldn’t attempt to overcome this documentation hurdle by copying and pasting notes. The note in the EMR must sufficiently describe the services furnished to that specific patient at the coded encounter. If every chart is worded similarly, you may have a problem, warns Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a medical coding and billing company in Bedford, Mass. One of the hottest areas for payer audits is looking for cloned documentation.

Myth 2: EMR Time Stamp Lets You Code by Time

One of the perks of EMRs is they typically record the date and time that information is input. In fact, many EMRs record a summary of the time spent at the end of each visit’s documentation and give a total, such as “Total time: 26 minutes, 15 seconds.”

Several subscribers have told TCI that they have used this time calculation to select an E/M code. For example, if the EMR says that the time spent is 25 minutes, these practices are automatically reporting 99214 (Office or other outpatient visit … Typically, 25 minutes are spent face-to-face …) for the visits, using the rationale that CPT^® allows you to code E/M services based on time.

Reality: The key to billing based on time is that counseling and/or coordination of care must dominate the visit, meaning it accounts for more than 50 percent of the time spent. Exceeding the 50 percent mark isn’t unusual in oncology, but the documentation must clearly show the time requirement was met for you to code based on time. An EMR’s notation of time spent in the record is not sufficient. Instead, the documentation must contain the following three elements:

·         Notation of the total time spent on the encounter

·         Notation of the total time spent on counseling and/or coordination of care, or the percentage of the visit spent on counseling/care coordination

·         A summary or notation of the topic discussed during counseling/care coordination.

For example, the following statements could support billing based on time alone: “25 minute office visit with 20 minutes spent on counseling about surgical and non-surgical options for breast cancer,” or “Total encounter: 35 minutes with more than 75 percent spent on coordination of care for patient’s metastatic lung cancer.”

In an EMR, you may not know where to put such a statement, but most of these systems are capable of providing a comment box or field to record this information when pertinent to the visit. As long as the provider enters the appropriate statement about time in the record, you can code based on time, but simply stating the total time spent — or letting the EMR calculate the total time for you — is not adequate.

Myth 3: EMR Code Selection Is Always Right

Your EMR may 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.

More than one practice has commented to TCI that their physicians thoroughly document the History and Physical Exam elements for all conditions, leading the EMR to suggest high-level E/M codes for established patient office visits requiring two out of three criteria (History, Exam, Medical Decision Making/MDM). The concern the practices share is that the MDM doesn’t support reporting a high-level code.

Reality: Medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT^® code. In addition, the 1995 E/M Guidelines state, “The documentation of each patient encounter should include: reason for the encounter and relevant history, physical examination findings and prior diagnostic test results.”

While high-level codes aren’t unusual for oncology encounters, not every visit will merit 99215 or even 99214. Therefore, you should use your EMR’s code selection as only a suggestion. The final code choice should be determined by the clinician and based on medical necessity and the nature of the presenting problem.