Oncology & Hematology Coding Alert

Insurers often fail to acknowledge the unique complexity of cancer treatment and the level of E/M services needed. This often leads to the carriers downcoding the claims. Then, frustration with downcoding and concern about audit or fraud allegations eventually cause oncologists to begin undercoding visits rather than taking the time to make sure documentation supports a higher-level code that could be justified but ultimately gets reduced.

Gary Bien, the practice administrator at Hematology/Oncology of Indiana, says lack of proper documentation is the chief barrier standing in the way of deserved higher reimbursement.

Without proper documentation, the oncologists are vulnerable. The specificity with which the oncologist dictates information regarding a case is always going to be the best basis for determining whether claims will be paid, he observes.

What Is Enough Documentation?

But how can you tell if theres enough detail in the chart? For example, would a level 5 new patient office visit (99205) be supported by the following notations: Patient is a 29-year-old female newly diagnosed with Stage I invasive breast cancer, upper outer quadrant (174.4)? She elected to have a simple mastectomy (19180) and a sentinel node biopsy (38792), which showed no cancer cells. The tumor was 1.2 cm in diameter and estrogen receptor negative. Chemosensitivity testing showed the tumor to be resistant to methotrexate. The patient has been married for two years, and she and her husband (who accompanied her on the visit) want to have children and are concerned that chemotherapy may put her into premature menopause.

She is also worried about her risk of recurrence because her mother died of breast cancer at age 35. She has joined a support group and has been searching the Internet and thus has questions about complementary therapies, particularly acupuncture and Chinese herbs, and how those might affect her prognosis.

The CPT criteria for a new patient office visit (99205) include these three key components: a comprehensive history, a comprehensive examination and medical decision-making of high complexity. The presenting problem(s) are of moderate to high severity, and the physician typically spends 60 minutes face-to-face with the patient and/or family. Therefore, check the patients chart to ensure the oncologist noted face-to-face time spent with the patient. Considering the complexity of care, the visit certainly could have taken 60 minutes or more.

According to Doris Byrem, practice manager at Davis, Posteraro & Wasser, an oncology group practice in Manchester, CT, Physicians tend not to count time. They may come out from a visit of more than an hour and not mention the duration in their notes.

Tip: Prolonged visits (99354-99357) are not unusual in oncology, particularly with newly diagnosed patients.

This case requires a comprehensive history and very complex level of decision-making about chemotherapy (the risks, benefits, side effects and likelihood of infertility from various protocols). It also involves counseling the patient about available pretreatment options if infertility occurs, such as freezing an embryo for later implantation. Education about complementary therapies also can involve a lengthy discussion, especially when the patient has done a lot of research and has many questions.

The chart should reflect all the chemotherapeutic options discussed as well as any anti-nausea medications or other drugs to control side effects. If those details are not spelled out, ask the oncologist if there is more to say about this claim because you think it might be denied if it cannot be fleshed out.

Byrem describes another scenario which could justify level 5 if documentation is thorough: When an oncologist meets with a patient who has metastatic disease that isnt responding to the current treatment, they need to go over the next treatment options, the side effects, etc., she says.

For example, a 73-year-old man with prostate cancer (185) has developed painful bone metastses in his right hip (198.5), indicating that his cancer has become hormone-refractory and that a different course of therapy is needed. In addition to pain-control medication, the options include focal radiation to the hip plus one of several chemotherapies (mitoxantrone [J9293], ketoconazole [J9999], suramin [J9999]) now in clinical trials.

Each of these therapies has significant side effects that need to be explained to the patient. Depending on a number of factors, the patient might decide to forego further treatment, except for pain control. This established patient visit could reasonably last 45 minutes (99214) to an hour (99215) or longer, which would make it a prolonged outpatient visit (99354-99355). Again, the chart should spell out all the issues discussed, the time spent, and the outcome of the discussion with the patient.

Consultation Documentation

If the details recorded by the oncologist are inadequate, ask him or her to review and amplify the documentation. Office consultations also need careful, thorough documentation to support level 4 and 5 codes (99244-99245). Consider the complex issues involved when an oncologist from another practice requests a consultation from an oncologist in your group on a 42-year old woman diagnosed with advanced multiple myeloma (203.00).

The requesting oncologist has suggested autologous bone marrow transplantation (38241) plus localized radiotherapy for bone pain and pamidronate (J2430), 90 mg intravenously monthly, to reduce the incidence of pathologic fractures.

Autologous bone marrow transplantation is a high-risk cancer treatment that itself can prove life-threatening. Reviewing the comprehensive history of this patient and completing a comprehensive examination cannot be done quickly. Such a consultation requires a complex level of decision-making and in-depth counseling and education of the patient. If the visit takes one hour, the consultation would be coded 99244. If it takes as long as 80 minutes, the code would be 99245. But of course, all the facts at times must be documented to justify the high level of service.

Summarizing, Bien says, Regardless of who the payer is they will downcode if they can, if the information is not there. Being able to back up billing with sound information is critical to stopping downcoding. If you continue to fight downcoding and you continue to win, the carrier will stoptheyll realize its not in their best interest. Unfortunately, a lot of practices dont have the strength of the documentation behind them to argue against downcoding or prevent it from happening in the first place. If more information is available that could strengthen a higher-level claim, ask the oncologist to provide it. As Bien says, The person who does a good sound job of codingincluding asking for more detailed informationcan more than pay for him/herself just out of charges that would have been lost or otherwise underbilled.