Oncology & Hematology Coding Alert

With reduced reimbursements for many of the services oncologists provide, practices need to be sure they are exploring all available opportunities. Listed below are four possible hidden pockets of revenue oncology practices can ethically take advantage of.

1. Chemo Chair Visits: Chemo Chair Visits can be billed using 99212-99213 (office or other outpatient visit for the evaluation and management of an established patient). We suggest that oncologists round through the chemotherapy infusion area at certain times during the day, answer patients questions and take care of any problems. This reduces interruptions during regular office visits, says Marty Neltner of Neltner Billing & Consulting in Newport, KY.

It not only helps the bottom line but increases efficiency and patient satisfaction. In many practices, the nurse interrupts the oncologist with questions about a patients blood counts or side effects, but the oncologist doesnt see the patient. Under that scenario, the visit is coded as a 99211a nurse-only visit.

But the chemo chair visit involves face-to-face time by the physician with the patient and an assessment by the oncologist. If the patient has questions, the assessment is brief, and the decision-making straightforward, the visit can be billed as a 99212, says Neltner. If the patient has a problem, the assessment is more thorough, and the decision-making more complex, the visit is billed as a 99213.

2. Prolonged Service (99354-99355): Based on his experience managing the National Oncology Practice Alliance (NOPA), a large network of independent oncology practices, Neltner believes oncologists tend to understate service time.

Although he acknowledges that there are different opinions, he feels the AMA definition of face-to-face time can mean the entire time the patient was in the examining room and things were going on to take care of that patient. It doesnt necessarily mean that patient and physician were eyeball-to-eyeball the entire time. For example, a breast cancer patient comes in; thats typically a 20- to 30-minute visit (99213-99214).

Shell have blood work. That and her scans show that her current chemotherapy isnt working and needs to be changed. So you talk about the optionsTaxol (paclit-axel J9265), Navelbine (vinorelbine J9390), docetaxel (J9170)counsel the patient, answer questions. Some of this counseling could be done by a nurse, but all this time counts as face-to-face E/M time, according to Neltner.

It may add up to an hour or more, so you would then have a 99214 or 99215 plus a prolonged service code 99354-99357 (prolonged physician service ... requiring direct [face-to-face] patient contact beyond the usual service). The oncologist can document that and validate it. And its very appropriate care for one hours work. That value is worth probably about $180 on the Medicare fee schedule. Thats what doctors dont understandthey dont even appreciate their own true value.

3. Hospital Rounds: Once a cancer patient is admitted to the hospital (99221-99223), subsequent visit codes (99231-99233) and discharge codes (99238-99239) may be overlooked. Oncologists generally see their patients every day, sometimes twice a day, and many times theres no tracking at the office to make sure fees are charged for the total time spent in those daily care visits to inpatients (99231-99233). When patients are discharged, oncologists may need a reminder to note the discharge code (99238-99239) so the visit for the final day also can be billed.

4. Care-plan Oversight: Oncologists who have patients under the care of a home health agency or in a hospice are entitled to bill monthly for care plan oversight (99374-99378), providing the physician has spent 15 or more minutes in a calendar month managing the patients care. Home health agency codes are 99374-99375 and hospice codes are 99377-99378.

According to CPT guidelines, the time doesnt have to be continuous but can be accumulated throughout the month. This time can include telephone calls between the physician and other professionals involved in the patients care, review of findings or reports about the patient and revision of the care plan. It cannot include time spent consulting the oncologists own staff, or physician calls to the patient or patients family.

Only the physicians activities count toward the total time, not the nurses time. The oncologist must have had a face-to-face encounter with the patient during the six months before the first month in which the service is billed. Medicare will not reimburse for care plan oversight if the oncologist has some ownership or financial or contractual relationships with the home health agency or hospice. Neither will Medicare reimburse the oncologist for services to the hospice that are billed to Medicare by the hospice.

All activities must be documented in the medical record, including the number of minutes involved. Some private insurers also will pay for care plan oversight for patients under the care of a home health agency or hospice. Unlike Medicare, these payers will also reimburse care plan oversight for patients in a nursing home (99379-99380). Restrictions for physicians who have a relationship with the home health agency or hospice do not apply. Depending on the contract terms with individual insurers, some payers may allow time spent instructing nurses and other staff to be counted toward the monthly total.