Oncology & Hematology Coding Alert

When an oncology-related visit takes longer than normal, the add-on, prolonged office visit codes (99354-99355) may be used to describe an extended visit with face-to-face physician-patient contact. However, a more prudent choice is to use office visit codes (99201-99215) with time as the determining factor if a visit is dominated by counseling the patient and/or family.
 
For instance, a patient presents for a scheduled chemotherapy visit but in addition to treatment, has questions about its progress, prompting the physician to spend time counseling the patient and reviewing the plan. What was initially a routine office visit, with nurse-only services, turned into a 45-minute face-to-face encounter between patient and physician in addition to the one-hour chemotherapy session.
 
In this case, oncology practices should report 99215 because face-to-face time exceeds the 40-minute threshold set forth in CPT 2002 for the highest-level office visit.

The single requirement for switching to time as the determining factor, rather than the combination of history, exam and medical decision-making, is that more than 50 percent of the visit be dominated by counseling of the patient and/or family.

 
Codes 99354-99355 should be used to report unusual circumstances, such as complications related to chemotherapy administration (96400-96549). One example occurs in orthopedic oncology. A visit may go something like this:
 
The orthopedic oncologist sees the patient, reviews all film, sends the patient for additional x-rays or computed tomographies (CTs), and sees the patient again to review and discuss the findings and develop a treatment plan. The reason this visit may warrant prolonged service codes is that the visit was not continuous and was not dominated by counseling, yet it required extra time to be spent with the patient gathering information and making complex decisions.
 
"We rarely use prolonged service codes," says Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett, N.H. "I only use them if the visit involves something out of the ordinary. Excessive use of these codes may raise red flags."
 
According to the CPT, 99354-99355 are used under two conditions:
 
1. When direct, face-to-face contact with the patient is beyond the usual service; for prolonged service on a given date, even if it is not continuous; 99354 should be used to report the first hour, while 99355 is reserved for each additional 30 minutes.
 
2. To report additional time as a result of unforeseen circumstances, such as the discovery of a new condition, or for extra time beyond what the physician normally spends with a patient.
 
 
The billing staff at Baptist Cancer Institute in Jacksonville, Fla., uses inpatient prolonged service codes (99356-99357) more often than the office-related ones.  However, hospital cases embody the seriousness that requires the extra time and services to treat these patients, says Nancy Cothern, practice administrator for the Institute.
 
Lengthy office visits are usually the result of time-consuming counseling, allowing the practice to report office visit codes using time as the determining factor.
 
To help determine whether adding a prolonged service code is justified, follow some other basic rules:

 

The codes may be added to any other physician service, including E/M services.
 

They may be used to report the total duration of face-to-face contact, even if the time is not continuous.
 

They may be used only once per date of service, even if the time spent with the physician was not continuous.
 

If the prolonged service was less than 30 minutes, then 99354 is not separately reportable and the service provided should be included with the normal E/M service codes.
 

Code 99355 is used to report time spent with the patient beyond the first hour; it must be between 15 and 30 minutes. If the time is less than 15 minutes, do not report 99355 in addition to 99354.

 
Unlike time-dependent E/M codes, circumstance is the triggering factor in reporting 99354-99355. The patient's medical record should detail the physician-patient encounter and explain why the physician spent extra time with the patient. Look for the following documentation:
 
New diagnoses codes. This can be an indication that a new condition was discovered that required the physician to lengthen the time spent with the patient.
 
Test orders that fall outside the norm. Tests such as a complete blood cell count may also prove that the physician noticed a new condition or was addressing a concern that required extra time.
 
Unusual or severe side effects from chemotherapy or chemotherapy-related drugs. Again, these are indications that the patient needed care beyond the normal scope of visits that were similar.
 
Lengthy counseling. Addressing the psychosocial aspect of patient care is an appropriate reason to report prolonged service. For example, a patient with concern about the effectiveness of treatment or with anxiety will require the physician to review the treatment plan.
 
While time is not the overriding factor, it can be used as a benchmark in deciding when prolonged service codes can be used. Codes 99211-99215 for office or outpatient visits are primarily governed by the three components of evaluation and management services history, exam and medical decision-making. CPT, however, defines "typical" amounts of time for each level of E/M service. For instance, 25 minutes is the typical time physicians spend with patients who meet the requirements for 99214.