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:

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 answers the patient's questions and has the patient sign the consent form for the chemo, she says.

Anytime you report 99211, the nurse or medical assistant should document the visit's reason, a brief history of the patient's illness, any exam processes such as weight or temperature, and a brief assessment, Reibman says. Look for notes such as "Wound has healed well," "Blood pressure is normal," or "Condition controlled with medication" to serve as proof that the practitioner met with the patient.

Any qualified personnel who are your oncologist's employees can report 99211, including medical assistants, licensed practical nurses, technicians, and other aides working under the physician's direct supervision.

Oncology coders often complain that CPT doesn't provide enough guidance as to what warrants a 99211-level visit. But a good way to determine if the visit qualifies is to know what your payer expects the medical record to show.

"What the payer expects to see if they were to review the medical records is that the service provided required more than simply collecting a specimen or the administration of an injection," says Judy Richardson, MSA, RN, CCS-P, senior consultant with Hill & Associates in Wilmington, N.C. "A bit more expertise should go into the record."

For example, the oncologist begins a patient's chemotherapy treatment (96400-96549) in the morning. Later that day the patient returns with nausea and vomiting (787.01). The nurse provides antiemetics, and the patient improves.

The nurse reports 99211 along with ICD-9 code 787.01. Will the carrier pay? Probably, because the nurse provided a diagnosis code of a minor problem and treated the condition with medication.

Not all nurse visits warrant reporting 99211. Suppose the patient phones your office and reports that her chemotherapy pump has broken. She returns to your office, where the nurse provides a new pump. Because the nurse simply gives her the new pump, you should not report 99211.

The new patient E/M codes do not offer an equivalent to 99211. Registered nurses cannot report 99201, the lowest-level new patient office visit code, because physicians must see new patients or established patients who have new problems before you can report 99211.

"Remember, however, that Medicare [and most other payers] does not pay for some services, such as 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) and 90788 (Intramuscular injection of antibiotic [specify]), with any E/M codes," Richardson notes. "This policy includes CPT 99211."

Also, you can no longer report most chemotherapy codes in addition to 99211. In January, Medicare essentially included payment for 99211 with the codes.

Example: The oncologist provides an hour of intravenous chemotherapy using a push technique. During the treatment the patient develops a severe headache, which the nurse treats. Even though the nurse provided a low-level E/M service (99211), you should only report the chemotherapy code 96408 (Chemotherapy administration, intravenous; push technique).

You should report only a higher-level E/M code, such as 99212, on the same day as chemotherapy. But you have to attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M, Reibman says.