Oncology & Hematology Coding Alert

Question: May we bill an insurance carrier for a prescription refill, especially for patients who have to physically stop at the office to pick up a script? The staff and doctor spend a lot of time answering these inquiries.

Virginia Subscriber

Answer: No. CPT specifically includes writing prescriptions as part of an E/M service. This is just part of the cost of seeing patients, much like office supplies. There is no CPT code that payers will reimburse for writing a prescription.

If the only reason the patient comes in is to pick up a prescription and the oncologist does not see her for a documented E/M service, you cannot bill an E/M code.

Helpful: Although prescription drug management is not a separately billable service, it can help to support a higher service level when your oncologist does see the patient for a documented E/M visit that includes prescription management.

Keep in mind: Prescription drug management contributes to choosing a "moderate" level of risk, according to the table of risk in the E/M documentation guidelines. You can find these guidelines online at http://www.cms.hhs.gov/MLNEDWebGuide/25_EMDOC.asp.

You typically associate a moderate risk level with a level-four established patient office visit, which also requires either a detailed history or a detailed exam.

Experts note: Medication management alone would not equal 99214. Medical decision-making includes three components: the nature of the presenting problem, the amount and type of data reviewed, and the level of risk.

If the patient has an established problem that is stable or improved, there are no labs or x-rays ordered or reviewed, but the prescription is refilled, code the service as 99212 (Office or other outpatient visit ...) instead of as 99214.