Oncology & Hematology Coding Alert

If you've been worrying that the oncologist's illegible signature on an order is going to come back to haunt your practice in an audit, CMS has offered answers on when you're safe and when that untidy scrawl could have reviewers requesting additional information.

With few exceptions, Medicare requires a signaturefor services and orders. CMS updated the rules and added e-prescribing language to the mix in Transmittal 327, CR6698 (www.cms.gov/transmittals/downloads/R327PI.pdf). The rules instruct contractors reviewing claims on what counts as a signature and when the services or orders must have signatures.

One important exception to the signature requirement is that "diagnostic orders need not be signed by the physician," says Kelly Loya, CPC-I, CPhT, consultant with California-based Sinaiko Healthcare Consulting Inc. Still, the medical record must include information verifying the ordering physician intended the test to be performed, and "a progress note in the medical record must be signed," Loya explains.

A helpful feature of the transmittal is a chart that "gives very specific facts as to what meets the requirements or requires follow up with the provider to meet the requirements," says Loya. For example, if you scan the chart, you can quickly see that an illegible signature written above a typed name is OK, but contractors won't count just an unsigned typed note with a typed name. "The reviewercan explore alternate methods in order to verify the signature requirement," Loya notes. But be warned: "Not complying with an attestation request (within 20 days of the request)" could lead to a denial, she says.

If you've been reporting G8553 (At least one prescription created during the encounter was generated and transmitted electronically using a qualified ERX system), be sure to give the transmittal a close look. The new e-prescribing language solidifies that for non-controlled substances, "as long as a 'qualified' eprescribing system (per Medicare Part D requirements) is used, a pen and ink copy" of the signed prescription order is not required, Loya says. But physicians can't eprescribe controlled substances -- for example, addictive pain medications -- so CMS requires a pen and ink order for these.

Watch for change: The Drug Enforcement Agency recently released its interim final rule on e-prescribing controlled substances. If your oncologist is willing to jump through the multi-step authentication hoops, e-prescribing controlled substances may be a possibility in the future. Transmittal 327 is effective March 1 with an April 16 implementation date.

In other news, the OIG released its 202-page "Compendium of Unimplemented OIG Recommendations," which revealed that many OIG suggestions have been ignored (download it here: http://oig.hhs.gov/publications/compendium.asp).

Case in point: In 2003, the OIG found a 40-percent error rate on claims that contained modifier 59 (Distinct procedural service) when used to separate Correct Coding Initiative (CCI) edits, resulting in Medicare paying $59 million in improper payments.

The OIG encouraged carriers to institute prepayment and postpayment reviews of the use of modifier 59, and suggested that CMS should update carriers' claims processing systems so they pay claims with modifier 59 "only when the modifier is billed with the correct code," the OIG report indicates. The OIG now says that CMS has not yet instituted such system edits, and notes that it will "continue to monitor CMS's efforts to implement edits to ensure correct coding."

What this means: "The OIG lists modifier 59 as a priority nearly every year, and it's possible that the agency feels that CMS should be looking more closely at its use," says Randall Karpf with East Billing in East Hartford,Conn. "The bottom line is that if all of these entities are watching modifier 59, make sure you're using it properly.

" In particular, past OIG investigations have shown that one of the more common modifier 59 mistakes is incorrectly unbundling 38220 (Bone marrow; aspiration only) and 38221 ( biopsy, needle, or trocar), so be sure you keep a careful eye on this code pair. (For more information on these codes, see "Bone Up on 38220, 38221, and G0364: CMS Coding Guidelines in Focus" in Oncology & Hematology Coding Alert, Vol. 12, No. 1.)

Plus: The OIG examined services billed using the "incident to" guidelines, which you should know well if you report oncology services to Medicare. As a result of the OIG scrutiny, CMS is revising its incident-to policies to reflect the fact that "no one except licensed physicians perform the services or nonphysicians who have the necessary training, certification, and/or licensure, pursuant to state laws, state regulations, and Medicare regulations perform the services under the direct supervision of a licensed physician."

Although many practices already follow this rule, the OIG "wants an explicit rule rather that the current implicit rule," says Quinten A. Buechner, MS, MDiv, CPC,ACSFP/ GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.