Oncology & Hematology Coding Alert

Oncologists routinely spend extra time with patients and their families explaining diseases and treatment. But oncology practices often code for these services incorrectly, or payers present barriers that inhibit billing for the added time spent with patients. To get paid for what you deserve, you should either use prolonged service codes (99354-99355) or use time as a factor when determining the level of an E/M visit with a Medicare or privately insured patient.
 
Modifier -21 (prolonged evaluation and management services), which indicates to Medicare carriers and private insurers the same thing as prolonged service codes, is similar to time-dependent E/M visit codes. However, modifier -21 deprives practices of the additional payment they deserve, says Nancy Giacomozzi, office manager for P.K. Administrative Services, a billing firm based in Englewood, Colo.
 
Options Depend on Carrier

To understand when to use the above codes and modifier, Giacomozzi says, oncology practices should first determine whether the patient is covered under Medicare or private insurance. For Medicare patients, the first option is prolonged service codes.
 
According to CPT, +99354 and +99355 are for three  conditions:
 

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.
 

Code +99354 should be used to report at least 30 minutes and up to one hour and 14 minutes, while +99355 is reserved for each additional 30 minutes after the first hour and 14 minutes.

Prolonged service codes are used to report added time due to unforeseen circumstances, such as the discovery of a new condition, or for the additional visit time beyond what the physician normally spends with a patient under similar circumstances. This is true for both Medicare and commercial carriers, but individual payers may not recognize these codes.
 
For those that do reimburse, +99354 and +99355 are add-on codes that must be used with the appropriate E/M code. For example, +99355 should be appended to 99213 (office or other outpatient visit) when the physician performs an expanded problem-focused examination that requires medical decision-making of low complexity and more than 30 minutes beyond what is normally spent performing that level of E/M.
 
But, if a physician performs a visit that meets the definition of 99212 a problem-focused history and exam, and straightforward medical decision-making and the total duration of the direct face-to-face contact, including the office visit, was 35 minutes 10 minutes for the visit and 25 minutes of extra time the physician cannot report prolonged service codes. This is because the total duration of direct face-to-face services did not meet the threshold time for billing prolonged services.
 
Also, if a physician conducts a visit that meets the definition of 99213 expanded problem-focused history and exam, and low-complexity medical decision-making while the patient was in the office receiving chemotherapy treatment for two hours, the total duration of the direct face-to-face service of the physician was 40 minutes 15 minutes of normal visit time and 25 minutes of extra time not associated with chemotherapy the physician cannot bill prolonged services. The reason for this is that the total duration of direct face-to-face service did not meet the threshold time required.
 
Another option for Medicare and private carriers is to use prolonged service codes and modifier -21, says Imelda Lee, RHIA, CTR, coding supervisor for University Physicians Group at the University of Texas Health Science Center in San Antonio.
 
With this coding procedure, the oncology practice would report the appropriate E/M visit code based on the key components of an office visit and would append modifier -21 and the prolonged service code that describes the amount of extra time. If the extra time does not meet the threshold for prolonged service codes, only modifier -21 should be appended to the visit code.

Some Medicare carriers do not recognize +99354-+99355, leaving only the visit codes and modifier -21 to report. In this instance, Giacomozzi says, oncology practices should use the visit codes without modifier -21. Instead, practices should report the visit by using time to determine the level of service.
 
For example, if a physician meets the requirements for 99212 but spends one hour and 15 minutes of face-to-face time with the oncologist discussing treatment with the patient and family, the practice should code 99213 or 99214 to account for the additional time.
 
Lee warns against using time to report 99215, the highest level of E/M service. She says it is inappropriate to use time to code three levels higher than the practice would have coded using the key components of an E/M visit. Code 99215 should be reserved for E/M visits with patients who are seriously ill and require a set of complex services, such as medical decision-making and examination.
 
It is also important for physicians to document accurately the time spent with patients and the reason for the added time. The patient record should note the start and end time of the visit. Also, the record should document the reason for the extra time, such as "extensive counseling."