Oncology & Hematology Coding Alert

Use ICD-9 code 185 for prostate cancer patients

When your oncologist evaluates a patient for possible prostate brachytherapy, determine whether the encounter was a consult or an office visit and report the treatment planning with 77263 - if the planning service shows a high level of complexity.

Prostate brachytherapy does not have its own unique CPT code, which leaves coders with questions about how to report each procedure ethically and gain maximum reimbursement for the office.

Read on for expert advice on reporting the patient's initial encounter with the oncologist and treatment planning. See next month's edition of Oncology Coding Alert for advice on coding for implant procedures, post-treatment planning, and consultations with physicists. Brachytherapy Patient Evaluations Get Level 4 or 5 Oncology offices usually encounter prostate brachytherapy patients in two ways: in the course of an evaluation and management service or during a consultation, typically at the request of a urologist, says Sandy McMaster, outpatient oncology financial specialist at Edward Cancer & Radiation Centers in Lisle, Ill.

During these initial visits, the oncologist generally documents and reports a level- four or level-five service. The first encounter with a brachytherapy candidate is very involved because the physician must be careful to rule out other treatment modalities (such as external beam treatments) before settling on brachytherapy, McMaster says.

Example: The oncologist sees Patient X, who has prostate cancer and may benefit from prostate brachytherapy. The oncologist spends 35 minutes taking a history, performing a physical examination, and considering various treatment options - then calls Patient X's family into the room and counsels them for 20 more minutes. Documentation qualifies this encounter as a level-five service.

On this claim, you should report:

99205 - Office or other outpatient visit for the evaluation and management of a  new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family, when the encounter is a new patient office visit. 99215 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family, when the encounter is [...]