Oncology & Hematology Coding Alert

Oncology is a nursing-intensive specialty. A fair amount of care is given to patients outside of the view of a physician. Keeping track of nurse-provided services is crucial if practices want to get fair reimbursement for the entire course of a patients treatment.

The most accurate way to bill for a short, nurse-only evaluation and management (E/M) visit is to use code 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician).

A common practice among oncology practices is to provide follow-up care during chemotherapy treatment. The patient sees the physician on the first day of treatment, but usually follow-up care a brief review of systems, checking for chemotherapy side effects and then making the decision to proceed with the chemotherapy as ordered by the oncologist is handled during nurse-only visits. Unless any excessive or unexpected side effects occur and are reported to the physician, treatment continues without higher levels of E/M services.

According to CPT, code 99211 is reserved for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the CPT says, the presenting problems are minimal. Typically, five minutes are spent performing or supervising these services.

The time spent with the patient may vary with the needs of the patient, says Mary Mulholland, BSN, RN, CPC, reimbursement analyst in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

In oncology time is not as crucial a factor as the services, says Elaine Towle, CMPE, practice administrator with New Hampshire Oncology and Hematology, an oncology practice in Hooksett, N.H. Nurse-only visits may take longer than five minutes because of a series of services performed during the visit. For example, a nurse may check a patients vital signs, monitor side effects and flush ports. Although the time needed to complete all of the services may be longer than five minutes, 99211 is still the only appropriate code. Higher levels of E/M service call for longer service time, but require a physicians presence and that the key components of an E/M service be completed.

When the Nurse Notices a Change in Condition

There are instances, however, when a nurse-only visit changes into a higher E/M visit. If a nurse, in the course of his or her E/M service, notes an excessive or unexpected side effect and reports it to the treating physician, the characterization of the visit changes if the physician takes part in the visit.

For example, when a nurse discovers an abnormality, a new problem or an exacerbation of an existing problem, he or she must notify the supervising physician, says Towle. Because additional care [...]