Oncology & Hematology Coding Alert

Your oncologist may have spent extra time, but you shouldn't. Select the correct codes for prolonged E/M services and move on. When your oncologist spends extra time with patients and families discussing treatment options, you face the following coding options:
1. Add a prolonged service code for the outpatient setting (99354, 99355) to the appropriate E/M service.
2. Append modifier -21 (Prolonged evaluation and management services) to the appropriate E/M code.
3. Report a higher-level E/M service than you would without the time spent. Use this breakdown for proper coding: 1. Report the prolonged service with direct (face-to-face) patient contact (99354 and 99355) if your physician spends a minimum of 30 minutes in addition to the typical face-to-face time with the patient that the CPT manual assigns to a level of service, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., a healthcare consulting firm based in Landsdale, Pa. For example, your physician performs an E/M service that lasts 90 minutes and warrants the established outpatient level-five E/M code, 99215, which typically takes 40 minutes, according to CPT. You should add 99354 for the additional 50 minutes beyond 99215's 40-minute allotment, she states.

You can report prolonged service codes even if the physician's time was discontinuous. What matters is the total duration of face-to-face time spent between patient and physician, says Sherry Wilkerson, RHIT, CCS, CCS-P, director of coding and compliance for Esse Health in St. Louis. And don't be misled by the language describing 99354. The "first hour" means anything from 30 to 74 minutes, Wilkerson says. Make sure you document the entire duration or time. Ask your physicians to record either the start and stop times of each visit they make with a patient or how much time they spend during each encounter, in addition to what they do during it, she says.

Documentation should include:

New diagnosis codes
Test orders that fall outside the normal or routine ones ordered
Unusual or severe side effects of chemotherapy or chemotherapy-related drugs
Lengthy counseling. 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 [...]