Oncology & Hematology Coding Alert

Billing for evaluation and management (E/M) services often is challenging. In cases where oncology physicians provide the highest level of E/M service plus additional examination for concurrent disease and extensive patient and family counseling, use modifier -21 (prolonged evaluation and management services) rather than add-on codes.

An oncologist who conducted a comprehensive history and examination on a patient in an office setting, then spent 40 minutes of direct, face-to-face contact with the patient and family discussing treatment options, would normally code 99215 (established patient, office or other outpatient visit) for the encounter.

It is conceivable, however, that the physician spends more time with a patient who has multiple or concurrent illnessessuch as lung cancer and emphysema. The medical decision is more complex and the physician needs to spend more time with the patient and family going over diagnostic results, discussing the prognosis and educating them about the diseases and their treatment.

While time is not usually a determining factor in deciding level of service, it does play a role in proving prolonged service. The CPT indicates average times for each level of service a physician can expect to spend with the patient while performing the three key components of an E/M servicehistory, examination and medical decision-making.

Despite the obvious additional time the patient with multiple or concurrent illnesses requires, there isnt a code for the higher level of service. To reflect the prolonged service, physicians have two choices:

1. +99354prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (30 minutes to 74 minutes)

+99355each additional 30 minutes

2. Modifier -21prolonged evaluation and management services: When the face-to-face or floor/unit service(s) provided is prolonged or otherwise greater than that usually required for the highest level of evaluation and management service within a given category, it may be identified by adding modifier -21 to the evaluation and management code number or by use of the separate five digit modifier code 09921. A report may also be appropriate.

Modifier -21 gives physicians an outlet if they use more time or effort than the highest level allows, says Laurie Lamar, RHIA, CCS, CTR, CCS-P, reimbursement specialist, with the American Society of Clinical Oncology in Alexandria, Va.

How do you decide which is the appropriate coding choice? Prolonged service codes, according to the American Medical Associations (AMA) CPT Assistant, are reserved for patient encounters where there is intermittent face-to-face contact with the patient. While +99354 and +99355 are designed for physician-patient contact that is beyond usual service, it differs from modifier -21 in the following ways:

Codes +99354 and +99355 are used with E/M codes 99211-99215 when direct face-to-face contact is provided intermittently, such as when the physician leaves the presence of the patient to perform other services.

Modifier -21 is reserved for E/M codes, such as 99215, when prolonged service exceeds normal service time and involves continuous face-to-face contact; face-to-face contact that is not interrupted by services that must be performed outside the presence of the patient.

Codes +99354 and +99355 can be used with all levels of E/M service as long as physicians can show prolonged service and intermittent face-to-face patient-physician contact.

Modifier -21 is reserved for only the highest level of E/M service, such as 99215; modifier -21 is not to be used with any other level of service.

Codes +99354 and +99355 have time requirements; for example, any service lasting for less than 30 minutes cannot be reported.

Modifier -21 requires no specific time increment; for example, if the added service for 99215 is 20 minutes, modifier -21 can be used.

Documentation is also important, Lamar says. To use modifier -21, the patient record must show the length of the visit to prove prolonged service. It also should show that requirements for the highest level of service have been met. She recommends noting the length of continuous, direct face-to-face contact between physician and patient, or listing the starting and ending times of the visit in the in the patients chart.

The CPT also indicates that a report may be appropriate. Lamar recommends that it accompany a paper claim and provide enough information for the payer to understand the circumstances that led to the prolonged service.

Some carriers may not have a price associated with modifier -21, and the report will be used to determine payment for the additional time and service. Consequently, physicians must clearly communicate the events of the encounter so the reimbursement fairly reflects the extra time and work.

Lamar also recommends that physicians send more than chart notes in the event that a non-clinician is reviewing the claim. They should be understood by the average person, Lamar says.

The key factor, Lamar reminds, is showing continuous face-to-face time. The AMA defines face-to-face time for coding purposes as time spent with the patient or family to perform such tasks as obtaining history, doing an examination or counseling.

Pre- and post-encounter time cannot be a factor in using modifier -21. Physicians routinely spend time reviewing records, tests and performing other services both before and after they see the patient. This should be considered non-face-to-face time and should not be included with the continuous face-to-face time a physician is citing to show services exceeding the highest level.