Oncology & Hematology Coding Alert

Newly diagnosed patients require considerable resources from oncology practices in the form of counseling and education about their condition, treatment options and prognosis. Family members, too, want to know what the future holds for their loved ones. It may not be possible to recoup all the time spent with patients during this period, but detailed documentation and skilled use of the evaluation and management (E/M), prolonged services codes and team conference codes can help.

Tip 1: Documenting
Consultations Appropriately

When an encounter with the patient is provided as a consultative service, its important that both the requestor and consultant follow the request-render-report standard stressed by Medicare and in CPT 2000. The patient should be referred by the other physician in writing, and the oncologists visit should be acknowledged to the other physician in writing, stating that he initially saw the patient in consult only, advises Susan Arfken, practice manager for Somerset Hematology and Oncology Associates in Somerset, N.J.

Use Medicare Transmittal No. 1644 issued in August as your guide:

1. A consultation is distinguished from a visit
because it is provided by a physician whose
opinion or advice regarding evaluation and/or
management of a specific problem is requested by
another physician or other appropriate source
(unless it is a patient-generated confirmatory
consultation).

2. A request for a consultation from an appropriate
source and the need for consultation must be
documented in the patients medical record.

3. After the consultation is provided, the consultant prepares a written report of his/her findings, which is provided to the referring physician.

Similarly, according to CPT 2000, The written or verbal request for a consult may be made by a physician or other appropriate source and documented in the patients medical record. The consultants opinion and any services that were ordered or performed must also be documented in the patients medical record and communicated by written report to the requesting physician or other appropriate source.

Tip 2: Counseling Time to Determine E/M

Time spent counseling patients about their prognosis and treatment options can consume an oncology visit. With appropriate documentation, that counseling time can override the other criteria used to determine the E/M level.

Some oncologists overlook this, but you can bill for counseling when it takes up more than 50 percent of the total time of the visit, instead of going by the level of history, exam and medical decision making involved, explains Laurie W. Lamar, RRA, CCS, CTR, CCS-P, reimbursement specialist at the American Society of Clinical Oncology.

For example, after an initial visit and diagnostic tests, you may meet with a patient for 25 minutes. If you spend only ten minutes examining the patient, and devote the remaining 15 minutes to counseling her about her prognosis and treatment options, you can bill a level four E/M visit (99214), even though the visit may not have involved a detailed history or examination. CPT 2000 defines the 99214 as covering an office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components:

-A detailed history;
-A detailed examination;
-Medical decision-making of moderate complexity;
and
-Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.

Be careful to document the total visit time, the counseling time, and what youre counseling the patient about, Lamar advises.

Tip 3: Make the Most
of Prolonged Service Codes

For particularly long counseling sessions of more than 30 minutes duration, consider using the 99354 prolonged service code (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour. [List separately in addition to code for office or other outpatient Evaluation and Management service]). Additional time beyond the first 74 minutes must be billed in 30-minute blocks using 99355 (each additional 30 minutes (list separately in addition to code for prolonged physician service.) If the last time period is less than 15 minutes, it cannot be billed separately, according to CPT 2000.

For instance, if the physician spent a total of 90 minutes with a patient and her family, use 99214 for the first 30 minutes, and 99354 for the remainder since this code covers the 30 minutes-74 minutes of time spent with the patient over the base codes coverage for this service.

When using these codes, you have to be specific in your documentation, indicating the entire time of
the discussion and the familys questions, says
Teri Montjoy, an account specialist for Pediatric Hematology/Oncology in Greenville, S.C.

According to CPT 2000, its acceptable to use the prolonged service codes even when the face-to-face, physician-patient contact is not in one unbroken session. Codes 99354-99357 are used to report the total duration of face-to-face time spent by a physician on a given date providing prolonged service, even if the time spent by the physician on that date is not continuous, states the CPT manual.

Tip 4: Use the team conference codes

You can recoup the counseling time of not only the physician, but other members of the oncology practice by using a team conference code under certain circumstances (99361medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care [patient not present]; approximately 30 minutes; 99362approximately 60 minutes).

Montjoys Pediatric Hematology/Oncology, for example, uses the team conference codes when the attending physician, nurses, medical social worker, and the account specialist affiliated with the practice meet with the parents of a newly diagnosed patient and discuss all aspects of the childs case; her prognosis, treatment options, family support needs, etc. The practice typically holds such meetings at the time of initial diagnosis, when the child has completed her treatment, and at the time of an apparent relapse, Montjoy reports.

Parents attend the meetings without the child-patient, so the conferences meet the criteria of the patient not being present. Obviously, a similar conference that included an adult patient would not meet this standard.

Tip 5: Know Major Carriers Coverage Limits

Even though Pediatric Hematology/Oncologys team conferences meet the appropriate criteria, the codes cannot be used with every patients carrier. Not all private insurers recognize the practice, notes Montjoy. For example, she explains, the codes cannot be used in billing to South Carolina Medicaid. As with so many reimbursement issues, youll need to investigate which of your major carriers handles reimbursements for counseling oncology patients.