Oncology & Hematology Coding Alert

Question: I code for an outpatient bone marrow transplant clinic, and my providers believe the vast majority of their evaluation and management (E/M) service notes should be coded as level 5. Most of these patients are on chemo or being monitored for toxicity from chemo, which puts them in the high-risk category, but the providers are having a hard time grasping that they also need to meet a high level in either problems addressed or data as well. They are expecting that just because a patient has cancer, the problem addressed is high. For example, they do not agree that a patient with acute myeloid leukemia (AML) in remission that is stable but on maintenance chemo with moderate data should be coded with 99214. How should I better educate the providers?

AAPC Forum Participant

Answer: This methodology of arriving at the highest level of office/ outpatient E/M services for oncology patients undergoing chemotherapy is common. It is also incorrect, so in situations like this, it is important to familiarize your providers with the most current E/M documentation guidelines.

In particular, you should make sure they understand while “drug therapy requiring intensive monitoring for toxicity” does meet the highest level of the risk of complications and/or morbidity or mortality of patient management element of medical decision making (MDM), that is only one of two elements necessary to reach a 99205 or 99215 (Office or other outpatient visit for the evaluation and management of a/an new/established patient, which requires a medically appropriate history and/or examination and high level of medical decision making …), the highest level of E/M service in those categories.

To meet the highest level of the number and complexity of problems addressed at the encounter elements as well, for example, the patient must have one or more chronic illnesses with severe exacerbation, progression, or side effects of treatment (defined as chronic illnesses with severe exacerbation or progression “or severe side effects of treatment that have significant risk of morbidity and may require hospital level of care”), or an acute or chronic illness or injury that poses a threat to life or bodily function (defined as an “acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment”). Educating your providers to clearly document when a patient has such conditions, using similar language to CPT^® to describe the patient’s problems in their notes, can help you explain how to support a level 5 E/M service, when appropriate.

If the patient’s condition(s) do not meet this complexity, the encounter will need to meet an extensive level of data in the amount and/or complexity of data to be reviewed and analyzed element, or you will have to report a lower-level E/M service. Either way, the E/M service level reported needs to be substantiated by information in the patient’s medical record and should reflect the level of service provided based on two out of three of the MDM elements.

The other option to support billing for a level 5 E/M service would be to document the total time the provider spent on the service on the date of the encounter, and bill 99205/99215 if that time reaches the codes’ time thresholds. This means documenting 60-74 minutes of total time spent on a new patient and 40-54 minutes of total time spent on an established patient on the date of the encounter. Documentation would need to detail time and the activities spent and must exclude time spent on other billed procedures.