Oncology & Hematology Coding Alert

Oncology physicians that usually jot down phrases such as normal, negative, and no problems found to show they examined a body system need to beef up their documentation to ensure they get paid for the level of evaluation and management (E/M) services they deserve, according to Cindy Parman, CPC, CPC-H, principal at Coding Strategies Inc., a medical coding consulting firm in Dallas, Ga.

Mike Lewis, healthcare consultant with Mathieson Moyski Seler & Co., a Wheaton, Ill.-based accounting firm that provides reimbursement consulting, says, Documentation is the key to avoiding missed payment opportunities under current exam criteria and will be a greater challenge under new, more detailed criteria.

In the January issue of Oncology Coding Alert (Five Tips for Maximizing Pay up During Initial Cancer Diagnosis Appointment, on page 5), we examined how poor documentation of patient history can limit coding for higher levels of E/M services, such as 99205 (office or other outpatient visit). History is one of the three key components that determine the level of service, in addition to examination and medical decision-making. Failure to properly document any one of the three can lead to incorrect billing or having to bill for lower levels of service.

Even if physicians properly document detailed and comprehensive histories, they also must meet the documentation requirements for detailed and comprehensive examinations before they can successfully bill for level four or level five services. Poor examination documentation, like poor history documentation, will result in having no choice but to code for lower level E/M services than were performed.

Create Better Documentation Habits

Lewis suggests that the patient chart should have a heading that states examination to provide a clear indication that the information written below the heading reflects the examination of the patient.

Physicians often forget to make notations in the patient record to support the medical necessity of performing a detailed or comprehensive exam. The physician must remember that not all medical conditions will support a level four or a level five E/M, Lewis says. The key is the severity of the patients chief complaint. Unfortunately, the physician listens to the patient describe the problem, but then often writes down only minimal notes regarding the chief complaint. Without more definitive notes an auditor cannot see the medical necessity of a level four or five exam and will reduce the E/M to a lower level.

Lewis also reminds oncology physicians not to forget to include notes about the constitution of the patient, such as general appearance. The physician usually observes the patients general appearance but often neglects to write it in the notes unless it is a negative comment. For an exam to be a detailed exam, the physician needs to document [...]