Oncology & Hematology Coding Alert

When a physician in your practice is out of the office or taking the day off, but his or her patient comes in for scheduled treatment, there is still an opportunity to bill under the absent physicians provider number, some experts say.

Often, services provided to a patient do not require the treating physician to have face-to-face contact with the patient, only that a supervising physician be in the office at the time of the visit. A patient undergoing treatment for cancer, for instance, must follow a strict protocol based on his or her oncologists treatment plan. Chemotherapy administration and related services are usually an integral part of that plan, and the importance of sticking to the protocol outweighs the need for a treating physicians presence. Oncology practices have struggled to bill such visits, however. Should they bill Medicare under the treating physicians provider number despite the fact that he or she was not in the office? Or should they bill under the supervising physicians provider number?

According to the American Society of Clinical Oncology (ASCO), either method of billing can be defended legitimately. Just be able to explain your choice.

Coding experts say vague Medicare guidelines allow billing either way. Its a complicated issue, admits coding consultant Lillie McAlister, CPC, president of Double Diamond Enterprises, a coding and billing consulting firm in Conroe, Texas.

Incident-to Requirements

The issue of billing properly for services not provided directly by a treating physician revolves around incident-to guidelines, a concept unfamiliar to many oncology practices. Incident-to services are those not provided by a physician, but by a nurse, nurse practitioner (NP), or physician assistant (PA). Although the physician did not perform the services, he or she still is entitled to reimbursement because the services are considered integral to patient care. In oncology, chemotherapy administration (96400-96549), which most states allow nurses to perform, is a common incident-to procedure. At the heart of billing for chemotherapy administration and other services that can be performed by a non-physician is the absence of face-to-face physician contact.

For physicians to bill services as incident-to, practices must ensure that three criteria are met:

1. A physician who is a member of the oncology
practice but not necessarily the patients own
physician must be present in the office at the time services are provided;

2. The PA, NP or nurse who administers the service is
employed by the oncology practice; and

3. The procedure represents an expense to the physicians practice.

Incident-to requirements state that a physician does not have to perform all of the services billed under his or her provider number, and that there are services such as chemotherapy administration that can be provided by a nurse. Because of this, McAlister recommends that oncology practices bill incident-to services such as chemotherapy administration and related services to the treating physician, despite his or her absence.

By providing employees and bearing other costs associated with incident-to services such as nursing time, drugs and supplies practices can make the argument that they incur legitimate expenses when providing such services. He [the oncologist] is paying for his employees and for the cost of the drugs, reasons McAlister. It is his business that he is running.

A Stricter Interpretation of Incident-to

There are those who interpret incident-to more strictly. Phyllis Klein, president of P.K. Administrative Services, a Lakewood, Colo.-based medical billing agency, and president of the Association of Oncology and Hematology Administrators, says oncology practices in almost all cases should bill under the provider number of the physician present in the office the day of the visit.

Medicare is very clear that no drug or treatment can be billed without a physician present, says Klein. Because the [primary] doctor wasnt there, he cannot bill for incident-to services. It should be the [on-site] treating physician who bills for the service as long as he signs off on the notes.

ASCO, however, has found that Medicare carriers vary in their advice on this type of billing. To be on the safe side, the society recommends that oncology practices check with their local carrier before filing a claim. It further advises oncology practices whether they bill for the absent treating physician or for the present supervising physician to identify the physician that is present to avoid any appearance of fraud.

To make a case for either billing approach, you must understand the key elements involved. For example, direct physician supervision is essential if a practice is to bill services provided by a PA, NP or nurse as incident-to. Medicare specifies that supervision can include services provided by auxiliary personnel other than nurses and mid-level providers. Services provided by therapists, technicians and aides also may be billed as incident-to physician services.

Medicare guidelines explicitly state that a physician does not have to perform professional services in conjunction with incident-to services. Rather, incident-to services can occur without professional services occurring at the same time if the service is part of the course of treatment and reflects the physicians active participation in the management and care of the patient. There must be direct, personal, professional services furnished by the physician to initiate the course of treatment of which the service being performed by the non-physician practitioner is an incidental part. The physician also should perform subsequent services to show active participation in the care and treatment of the patient.

Direct supervision does not mean that the physician must be in the same room with the nurse or other clinical staff providing incident-to services. According to Medicare guidelines, a physician must be present in the office and immediately available to provide assistance and direction throughout the time clinical staff is performing services.

Document E/M Visit in Addition to Incident-to

An office visit for chemotherapy administration or related services also qualifies as an evaluation and management (E/M) service. If the visit is done outside the presence of a physician but with the supervising physician in the office, 99211 (office or other outpatient visit) is the appropriate code. In this case, it is not appropriate to bill under the absent physicians provider number, says McAlister. Instead, the oncology practice should bill the E/M service under the supervising physicians provider number.

When billing 99211, the nurse or other practitioner should document the date of the visit along with a brief description of the reason for the visit, such as heparin or saline port flush. The chart notes also should include the name of the supervising physician. Such documentation allows an auditor to know both why the visit was necessary and that a physician was available in case a complication was discovered.

The guidelines for billing 99211 apply to all services that may not require the presence of a physician, including evaluations performed by PAs and NPs, who also may bill incident-to the doctors services.

Unlike registered nurses (RNs), PAs and NPs have their own billing numbers, and therefore use the same guidelines as a physician. PAs or NPs either can bill using their own billing numbers, or incident-to the physicians services using his or her provider number.

In addition to the debate regarding whose billing number is the most appropriate the treating or supervising physician experts agree that treating physicians who are called away on an emergency and cannot be present during a visit still can be reimbursed for the scheduled care.

In cases such as these, practices should document the fact that the primary physician was called away on an emergency, the reason for the emergency and the presence of a supervising physician in the absence of the primary physician.

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Billing Incident-to for Services Provided Outside Your Practice Deciding how to bill incident-to services when the patients primary physician is out of the office is tough enough when the supervising physician is a member of the practice, but the rules change when the supervising physician comes from outside the practice. According to experts, including the American Society of Clinical Oncology (ASCO), oncology practices can bill for either the patients primary physician for scheduled incident-to services when the physician is absent, or they may bill the physician partner providing direct supervision. But what about the small oncology practices that have to rely on reciprocal arrangements to ensure that their patients follow protocol and that non-physician staff are given direct supervision? If the absent oncologist makes reciprocal arrangements with another oncologist who is not a member of his or her practice or pays a locum tenens (substitute physician), the services provided by the substitute physician can be billed under the absent physicians provider number. There is an accommodation that has been made for two physicians who exchange call coverage, says Lillie McAlister, CPC, president of Double Diamond Enterprises, a coding and billing consulting firm in Conroe, Texas. It might nullify the position that you cannot bill for a service you did not actually provide. Under normal circumstances, McAlister advises oncology practices to bill chemotherapy administration and related services under the primary physicians billing number and 99211 (established patient, office or other outpatient visit) under the supervising physicians provider number. Using the locum tenens modifier, oncology practices can bill even the evaluation and management service under the absent physicians provider number. In Texas, for example, oncologists have two modifiers to describe a situation when a physician is not in the office: -Q6, which tells Medicare the physician was not in the office but paid a locum tenens to provide direct supervision; and -Q5, for service provided by a substitute physician under a reciprocal billing arrangement. We currently use the -Q6 modifier to bill for the locum tenens who substitutes for our physician on the weekend, McAlister says. Medicare regulations state that a physician may submit a claim for services that were provided by a substitute physician if the following components are met: The regular physician is unavailable to provide the visit services; The Medicare patient has arranged or seeks to receive the visit services from the regular physician; and The regular physician identifies the substitute physician services by using the modifier -Q5 after the procedure code. The regular physician should keep a record of services provided by the substitute physician, along with the substitute physicians provider number. The substitute physicians provider number, however, does not need to be included on the claim form.