Oncology & Hematology Coding Alert

Beware of commonly overlooked prolonged service requirements. The face-to-face time must involve the physician and not other staff members, Wilkerson says. And the face-to-face time that the add-on code describes typically kicks in when the physician finishes the medical decision-making, Falbo says. "The clock doesn't start as soon as the patient comes into the office." The add-on code's time is in addition to the expected time already accounted for in the E/M code.

2. Report the E/M service with modifier -21 only when the additional time spent is less than 30 minutes. If your physician exceeds the recommended time spent on an E/M service by only 20 minutes, for example, you can still get payment for that time by appending modifier -21 to your E/M. You will typically increase your payment from 25 to 35 percent with that modifier, Falbo states.

Drop the claim to paper when you use modifier -21, Falbo adds. You must send a letter that says, "We're requesting X amount of increase above and beyond for the additional time," she says.

Do not use modifier -21 if you can use the prolonged services codes, Falbo says. And don't use modifier -21 if the physician's time spent is intermittent. As opposed to the prolonged service codes, modifier -21 requires that the physician have continuous face-to-face contact with the patient, she says.

3. Report a higherE/M service than you would with time spent if the physician spends more than 50 percent of the visit counseling or coordinating care. You must document the time and a summary of what transpired during the counseling and coordination of care, Wilkerson says.

Remember that time spent counseling doesn't necessarily have to involve the patient, Falbo says. If a family member is physically present, you can bill for the office visit. But you can't report the visit if that coordination of care and counseling took place over the telephone.

You may not always want to report a higher-level E/M service for your physician's time. You have to weigh what's in your best interest, Wilkerson states. If you have the highest E/M level (99215), you can't bump that up a level. But if your physician spends one and a half hours and more than 50 percent of his time during that visit counseling the patient, "You're shortchanging yourself if you don't use the prolonged service codes," she says.

Additional comment: Don't report prolonged physician service codes for that time spent without direct face-to-face patient contact (99358, 99359). Payers, including Medicare, usually don't reimburse them because the time spent typically involves physicians conferring with other doctors, checking records or talking to the family not with the patient.

You may try using the team conference codes, 99361 (Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care [patient not present]; approximately 30 minutes) and 99362 ( approximately 60 minutes). Take a look at the appropriate section in the CPT manual, because if your physician engages in a multidisciplinary discussion with other physicians, you could report these codes, Falbo says. Some payers reimburse for the management activities these codes describe. Discuss with your payers whether they reimburse these codes and whether they require you to append 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 service, Falbo says.