Oncology & Hematology Coding Alert

Solid documentation is more important than you may think Although many carriers no longer pay for 99211 and a chemotherapy code when the oncologist or nurse performs the services on the same day, you shouldn't give up on the office visit. You can report 99211 and get paid as long as the visit meets the criteria. The key is applying the code only when the practitioner provides a medically necessary service to an established patient and the practitioner has the training or necessary credentials to perform the service according to state and payer requirements.

"Be very careful when you bill for 99211," says Kelly Reibman, CPC, a billing representative for an oncology practice in Easton, Penn. "If you feel there is not adequate documentation to support a level one, then do not bill." For instance, if the medical assistant or nurse writes only "patient here for complete blood count," you should not report 99211, she adds. And remember, although we often refer to this code as the "nurse's code," your oncologist and other personnel could report it if an E/M visit doesn't meet the documentation requirements of the higher-level established patient E/M codes (99212-99215) but satisfies the 99211 criteria. And, some Medicare carriers, such as HGSA, the Part B carrier for Pennsylvania, have issued a clarification regarding 99211 use, says Mary Mulholland, BSN, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia. "Our carrier is restating the requirement of the physical presence of the physician in the office when the service is provided (to provide direct physician supervision) whenever this code is reported."

Coding experts recommend that you report 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) if the service meets three criteria: 1. Staff Performs an Actual E/M Visit To report 99211, a practitioner must perform an E/M service, so don't use 99211 to get any simple service paid.

What doesn't work: A nurse speaks to a patient on the phone and agrees to obtain a prescription refill for her. The patient comes to the practice an hour later, and the nurse hands her the prescription through the reception window. Because the nurse did not evaluate the patient and no medical necessity required that she meet with her, you should not report an office visit.

A better way: A patient presents to the nurse for orientation prior to chemotherapy treatment, Reibman says. The nurse may document an hour spent discussing chemotherapy's risks. Your nurse also [...]