Oncology & Hematology Coding Alert

Question: We are reporting an E/M encounter for a follow up patient with Hodgkin’s lymphoma. Our physician recorded vitals and obtained history but did not perform a physical examination. Our physician however has documented a detailed treatment plan for the patient. Does this encounter qualify for E/M code?

Vermont Subscriber

Answer: You will need the following information before you can pick up the E/M code:

• Where did the visit occur? 
• Was this follow up visit rendered in the physician office or hospital?
• If hospital, was the patient inpatient or observation status?

Most follow up visits require only two of the three components (history, examination or medical-decision-making) to support the level of care rendered. Below are the options we described, but there could be more if the location isn’t listed above.

• The established patient E/M codes 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components ...).
• The subsequent inpatient hospital patient codes 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:...).
• The subsequent observation care codes 99224-99226 (Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:…).

Since your clinician has recorded history and documented the treatment plan (medical decision making) and the patient is an established patient, you won’t need your clinician to perform a physical examination for you to report an E/M code for the visit for any of the sets of codes listed above.

Note: The 1995 and 1997 versions of the documentation guidelines for E/M services are maintained by the Centers for Medicare & Medicaid Services consider recording vital signs to be part of the physical examination.