Oncology & Hematology Coding Alert

Question: Two to three weeks after a hysterectomy, a patient begins chemotherapy. The oncologist bills 99236 to report observation of chemotherapy, using diagnosis codes V58.1 (Chemotherapy) and 183.0 (Malignant neoplasm; ovary) to show medical necessity. Medicare denies 99236, claiming it is part of postoperative care. I have tried using modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) because it was part of a staged protocol, but it is still denied. How should I code this?

New York Subscriber

Answer: A surgical code includes the one related E/M encounter subsequent to the decision for surgery on the date immediately prior to or on the date of the surgery, including history and physical. The immediate postoperative care, including dictating operative notes, talking with the family and other physicians, writing orders, and evaluating the patient in the postanesthesia recovery area, and the typical postoperative follow-up care during the global period are also part of the surgical package.

Complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services should be separately reported and are not included in the surgical package.

Code 99236 (Observation or inpatient hospital care requiring a comprehensive history, comprehensive examination and medical decision making of high complexity) should be reported for a patient admitted to the hospital for observation or as an inpatient.

Typically in the situation you describe, the gynecologist-oncologist performing the surgical procedure also provides the chemotherapy. The chemotherapy visit is not included in the global package for the surgical procedure because it is not typical postoperative care for a hysterectomy. It is an additional service provided for the diagnosis of cancer. The diagnosis for this visit is not the hysterectomy, but the cancer. Common cancer diagnoses requiring this surgical procedure include cervical cancer (180.x), ovarian cancer (183.x), or uterine cancer (182.x).

If a patient sees the physician for a review of systems and determination of chemotherapy orders, the appropriate E/M code should be used based on the level of service provided (99212-99215, Office or other outpatient visit for an established patient) by the physician. If the patient does not see the physician and is treated by nurses employed by another entity, such as a hospital, the physician cannot bill for any services.

If the physician employs or contracts the nursing staff who administers the chemotherapy, the practice may also bill for the chemotherapy drugs and the appropriate procedure codes for the chemotherapy administration.

However, when the patient visit is only with the employed/contracted nursing staff, and the nurse performs the ROS, laboratory result review, communicates this to the physician and obtains orders for the chemotherapy, 99211 (nurse visit) should be billed along with the codes for the chemotherapy drugs and the appropriate procedure codes for the chemotherapy administration.