Oncology & Hematology Coding Alert

Question: Can we bill an insurance carrier for a prescription refill, especially for patients who have to 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.

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. You should associate a moderate level of risk with a level-four established patient office visit, 99214 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity). Remember: Code 99214 also requires either a detailed history or a detailed exam.

Lesson: Medication management alone is not enough to justify using 99214.

Medical decision-making includes three key components: the nature of the presenting problem, the amount and type of data reviewed, and the table of risk.

If the patient has an established problem that is stable or has improved -- and no labs or x-rays were ordered or reviewed -- but the patient's prescription is refilled, you would most likely code for this using 99212 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making) instead of 99214.

Bottom line: Prescription drug management supports a "moderate" level of risk, according to the table of risk in the E/M documentation guidelines, which is one-third of the medical decision-making component. You can find these guidelines on the CMS Web site at http://www.cms.hhs.gov/MLNEDWebGuide/25_EMDOC.asp.