Oncology & Hematology Coding Alert

A little E/M information can be a dangerous thing because a vague grasp of an E/M rule can lead you to apply it incorrectly. But you can save yourself from these troubles with this look at how to steer clear of two common E/M pitfalls.

If your oncologist has to exert excessive effort to obtain an appropriate patient history, don't assume you may automatically choose your E/M code based on time.

Why: To bill based on time, the majority of the oncologist's time must be spent in counseling or coordination of care.

Example: A new patient who cannot speak English presents to your practice. The patient's inability to communicate prevents your oncologist from getting her complete history of present illness (HPI) and review of systems (ROS).

Your oncologist calls the patient's two previous physicians to discuss her medical problems and discovers that she also has diabetes and had an organ transplant five years ago. Including face-to-face patient time (45 minutes) and telephone calls (45 minutes) to other providers, your oncologist spends a total of 90 minutes on this patient on the same day. But only the face-to-face time actually counts toward your E/M code choice.

What to do: You should select the appropriate new patient code (99201-99205) taking into account the information your physician was able to obtain from both the patient and her other physicians.

Rule: If you want to bill based on time, the physician must spend more than 50 percent of the total face-to-face time counseling and/or coordinating care with the patient. If your physician's encounter does not meet this requirement, you cannot bill based on time.

In most cases, you cannot bill based on time if the physician states that a communication barrier extended the face-to-face time with the patient because that normally won't meet the counseling/coordinating care criteria.

The physician may document the excessive effort of trying to get an appropriate history and a reason for why he was unable to obtain the full history. The physician may then receive credit for the "unobtainable" history in the medical decision-making area.

If the physician documents service time when the patient is not physically present (such as post-exam calls to other physicians), you will probably be unable to report this time to most payers, says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky.

Most payers consider extra time, as noted in the example above, to be part of the pre- and post-service work associated with the E/M service payment.

Your oncologist may delegate some tasks to a nurse while he's seeing other patients, but can you use a nurse's notes to satisfy elements of ROS and past, family and social history (PFSH) for a new patient visit?

Good news: As long as the physician signs the nurse's notes and documents that he reviewed them, you can meet the ROS and PFSH requirements with information from the nurse's notes, says Susan Vogelberger, CPC, CPC-H, business office coordinator at Beeghly Medical Park in Ohio.

"I tell the physician to sign and date the nurse's note, as well as to refer to it in his own notes," Vogelberger says. You-ll use ROS and PFSH, along with the patient's physician-documented HPI, to decide the information level the oncologist gathered about the patient's history.

Keep in mind: Medicare states that either the patient or nurse can fill out a history form for ROS and PFSH.

Key: The physician must note in his visit documentation that he reviewed the information to use this when selecting an E/M service code.