Oncology & Hematology Coding Alert

Question: Our oncologist spends a lot of time discussing treatment options, imaging results, and other issues with patients. How should she document this to support coding E/M based on time?

Arizona Subscriber

Answer: When counseling and/or coordination of care take up more than 50 percent of the encounter, and you choose to code based on time, CPT's E/M guidelines tell you "the extent of counseling and/or coordination of care must be documented in the medical record."

Medicare's 1995 and 1997 E/M documentation guidelines (www.cms.gov/MLNEdWebGuide/25_EMDOC.asp) add that the physician should document the total length of the encounter and "describe the counseling and/or activities to coordinate care."

Remember: In the office or outpatient setting, you should count face-to-face time. In the hospital or in a nursing facility, you may count floor/unit time, according to both CPT guidelines and Medicare's documentation guidelines.

Example: The physician may document that she spent 20 minutes of a 25-minute encounter with an established patient discussing CT scan results and going over the likely outcome of chemotherapy. The physician fills in the remaining details of the visit, as appropriate.

In this case, based on the 25-minute session, report 99214, which specifies the visit usually lasts 25 minutes:

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: 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.