Oncology & Hematology Coding Alert

Determine whether you-ve grasped the subtleties of this tricky code set

Reporting E/M codes requires a lot of study beyond reading the code descriptors. Try your hand at these two questions that tackle tough E/M issues.

Questions:

1. True or False. The rules say that I can bill a level 99215 (Office or other outpatient visit for the evaluation and management of an established patient) based on history and examination if I can substantiate in the record a comprehensive history and examination, even though the medical decision-making is low risk and there is no data to review.

In other words, I can report 99215 regardless of medical necessity for that exam level.


2. When you report an E/M service on the same day as another procedure, do you need a separate diagnosis code for each CPT code?

Next step: compare your answers to the experts-.

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Are you an E/M coding master? Find out below.

Answers:

1. False. -CMS indicates in its Carriers Manual that -Medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT code,- - says Stephen R. Levinson, MD, author of the AMA's Practical E/M: Documentation and Coding Solutions for Quality Health Care.

Tip: Specialty societies developed and approved the Clinical Examples in Appendix C of CPT to illustrate the level of care warranted by representative patient problems, Levinson says.

Example: The 99215 example for oncology and hematology is an -office visit for restaging of an established patient with new lymphadenopathy one year post-therapy for lymphoma.-

Remember: Simply meeting the description of the clinical example is not enough to report the code -- documentation must still support the visit level you charge.

E/M Guidelines also point out the need to base your code on medical necessity. Example: Page 10 of the 1995 E/M Guidelines says, -the extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s).-

-The clear message here is that the history, exam and medical decision-making performed should correlate

with the presenting problem(s),- says Erica D. Schwalm, CPC-GSS, CMRS, billing and coding educator in Springfield, Mass.

 

2. No. When reporting any E/M service, you must link it to a diagnosis that explains the reason the physician performed the service. The E/M service does not have to be unrelated to the other service(s) or procedure(s) the physician provides on the same day, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.

CPT specifically states, -The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date.-
 
But separate diagnoses, when available, do further help to demonstrate the distinct nature of the E/M service -- especially when dealing with payers other than Medicare, says Raequell Duran, CPC, president of Practice Solutions in California.

Example: A patient presents for chemotherapy  related to a breast neoplasm (96413, Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug; V58.11, Encounter for antineoplastic chemotherapy and immunotherapy; encounter for antineoplastic chemotherapy; 174.6, Malignant neoplasm of female breast; axillary tail).

During the encounter, the patient requires a level-two E/M service for severe nausea (99212, Office or other outpatient visit for the evaluation and management of an established patient ...; 787.02, Nausea and vomiting; nausea alone).