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.
Use 99354-99355 Sparingly  
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 [...]