Oncology & Hematology Coding Alert

Never assume certain cancer diagnoses merit high-level E/Ms

You-re more likely to report CPT 99213 and 99214 than other established patient E/M codes, but watch out. Payers audit 99214 more than any other E/M code. Follow our tips to determine when you can bump your visit up to 99214 and when you should stay in the 99213 zone.

Nail Down 99213 and 99214 Elements

Pay attention to the differences in the descriptors for 99213 and 99214:

- 99213--Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

Usually the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

- 99214--- a detailed history; a detailed examination; medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's 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.

You can successfully code and document level-four established patient office visits (99214) for many of your oncology patients by remembering the code's minimum criteria. Compare 99213's to 99214's 1995 E/M documentation guidelines.

Watch These Common Upcoding Mistakes

If your oncologist's documentation supports a level-four visit, you should report 99214. But watch out for these hidden traps:

1. To count as a component of your documentation, the history must be pertinent to the patient's current condition. Just because a patient marks on her intake sheet that she had hand surgery in the past doesn't mean that you can count that as an additional system review, unless the condition is pertinent to her cancer diagnosis.

Payers and auditors may view obtaining a higher-level component than medically necessary just to charge a higher-level E/M service as -gaming the system,- says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions in Tinton Falls, N.J.

2. -Oncology MDM [medical decision-making] can be more intricate or complex than other specialties,- says Beth Potratz, CPC-A, with the Cancer Treatment Center in Swansea, Ill.

But remember that E/M codes aren't diagnosis-driven, she says. Don't assume you can report higher-level E/M codes for oncology patients--base your E/M choice on the documentation.

Example: An established female patient with a primary neoplasm of the lower-inner quadrant of the breast (174.3, Malignant neoplasm of female breast; lower-inner quadrant) comes to the office. You know this case has required moderate-complexity MDM in the past, but at this appointment the oncologist performs an expanded problem-focused exam and medical decision-making of low-complexity:

- limited diagnoses or management options
- limited amount and/or complexity of data to be reviewed
- low risk of complications and/or morbidity or mortality.

This service merits 99213, not 99214.

Coding Every Visit as 99213 May Send Red Flags

Some insurers put up red flags when a practice only reports 99213 for established patient E/M services, says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky.

Payers wonder what type of patient care a practice is providing when they never code anything higher or lower than that, she adds.

Solution: Choose your E/M code based on the oncologist's documentation every time, and your coding will naturally reflect the oncologist's range of services.