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 [...]