Oncology & Hematology Coding Alert

Question: A patient presents for a consultation, and Medicare is billed 99245. The patient returns a week later to further discuss treatment options without an exam being performed. How should the second visit be coded?

Washington Subscriber
 
 Answer: If the patients care was transferred to the consulting physician, established patient codes 99211-99215 should be used. There are two options in selecting the level of E/M service. The first option is to determine the E/M level using the three key components of history, exam and decision-making. 
 
Because the visit described consists mostly of discussing treatment options, the second option falls under an exception that allows time to be the determining factor, rather than the key components. This exemption is described in the CMS 1995 Documentation Guidelines for Evaluation and Management Services, which discusses visits that are predominantly of counseling or coordination of care. 
 
An established patient requires the documentation of two of the three key components. The two will vary from case to case. Because the patient is established, performance and documentation of a physical exam is not required.
 
The same can be said for either of the two remaining key components. To bill for an established patient visit, you must have documentation of an interim history and some degree of decision-making. The visit is likely to include low levels of history and medical decision-making because discussion of treatment options made up the majority of the visit. Therefore, 99212 is the most likely code.
 
However, it sounds as if counseling and/or coordination of care dominated (more than 50 percent) the physician/patient and/or family encounter. E/M codes contain, within the description of the code, the time that the physician typically spends with the patient and/or family. This is the time component that determines the level of service. For example, if an hour is spent counseling the patient and family, the practice may report 99213.
 
When time is the key component, the total length of the encounter and a description of the counseling should be included in the documentation. Time is measured as the face-to-face time spent by the physician with the patient and/or family when the service is rendered in an outpatient setting or, in an inpatient setting, the time that the physician spends on the floor or unit directly related to the care of the patient. In addition to time spent face-to-face with the patient, this can be time spent reviewing the chart, discussing the patients care with other care providers, etc., and need not be at the patients bedside.

  Answers to Reader Questions and You Be the Coder provided by Margaret Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant in New Orleans; Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies in Dallas, Ga.; and Imelda Y. Lee, RHIA, CTR, coding supervisor with University Physicians Group at the UT Health Science Center in San Antonio.