Oncology & Hematology Coding Alert

Question: We have nurses routinely assess our oncology patients. What type of assessment qualifies as an established patient level-one E/M code (99211)?

California Subscriber

Answer: The answer depends on which carrier you're charging. You should determine what each of your payers considers as normal standard of care. If the normal standard of care is a brief assessment simply to make sure the patient is OK, payers will not pay for it, regardless of whether it is done by your nurses or physicians. Most payers do not pay for basic assessment because they consider it part of the treatment. Medicare considers basic assessment as a good standard of care and will deny many claims believed to have been beyond the normal standard of care.

To get paid for more than the basic assessment, you must show in your documentation that the nurse did more than just take vital signs. You must have an assessment note that shows the vital signs, that the patient had no complaints since the last visit, and that the patient hasn't lost weight or that weight has been maintained.