Oncology & Hematology Coding Alert

Question: I think my oncologists frequently perform established patient office visits that warrant coding at level four or higher, but I-m concerned about raising red flags for upcoding. Would you explain how I should determine when I-m justified in billing level four?

Tennessee Subscriber

Answer: Your first step in choosing the correct code is to look at the differences in the descriptors for 99213 and 99214:

• 99213 -- Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-
  focused examination; medical decision-making of low complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

- 99214 -- ... a detailed history; a detailed examination; medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.

To report a level-four service (99214), your physician must document at minimum two of the following: a detailed history, a detailed exam and medical decision-making of moderate complexity.

Important: You also need to be sure that the nature of the presenting problem and medical necessity support properly coding level four.

Experts warn: Some insurers put up red flags when a practice only reports 99213 for established patient E/M services. Payers wonder what type of patient care a practice is providing when it never codes anything higher or lower than that.

-- The answers for You Be the Coder and Reader Questions were reviewed by Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and past-president of the American Academy of Professional Coders National Advisory Board. q