Oncology & Hematology Coding Alert

If your oncologist has to step in to treat a patient's adverse reaction to chemotherapy, be sure the doctor documents her work because Medicare wants to reimburse you.

To claim all of your practice's rightful dollars, keep your eyes peeled for the three circumstances below when you may report an E/M code in addition to infusion admin codes.

If a patient has an adverse drug reaction during a chemotherapy session and the physician intervenes, report the appropriate office visit E/M code based on the services provided (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...), states MLN Matters article SE0462. An anaphylactic reaction to the chemotherapy drugs may be the most common emergency you see, says Elisa Parra, CPC, HIM supervisor for Alta Bates Summit Comprehensive Cancer Center in Berkeley, Calif.

Key point: You should report the E/M code in addition to the infusion admin code(s) and expect payment for both. CPT's injection and infusion guidelines support this method by stating, "If a significant, separately identifiable Evaluation and Management service is performed, the appropriate E/M service should be reported using modifier 25 [Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service] in addition to 96360-96549." Codes 96360-96549 encompass the "Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration" subsection.

Example: During chemotherapy infusion, a patient becomes ill after 46 minutes of infusion time. The staff stops the infusion and calls in the oncologist for treatment. The severity of the reaction makes a level-three E/M necessary. You report the infusion using 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug). And you claim the E/M using 99213-25.

Money talks: Properly catching this E/M in the office setting will add approximately $65 to your bottom line, according to Medicare's non-facility national rate. (Search the fee schedule at www.cms.hhs.gov/pfslookup/.)

If the oncologist sees the patient before the chemotherapy session for a problem unrelated to admin supervision and also must intervene because of a significant adverse drug reaction, choose the E/M level based on the "total time, resources, and complexity of the physician's interaction with the patient," the MLN Matters article states.

Example: An established patient presents for chemotherapy. Upon arrival, she complains of fatigue over the last month, and the oncologist evaluates and manages the fatigue. Later during the same encounter date, the patient receives her scheduled chemotherapy infusion and develops an adverse reaction requiring the oncologist to assess her condition. The notes for the two services considered together qualify for a level-four office visit, so you report 99214-25 (Office or other outpatient visit for the evaluation and management of an established patient ...) in addition to the appropriate chemotherapy admin code(s). Adding the services to choose this higher level code brings in $99, based on Medicare's non-facility national rate.

Don't overlook: You also may consider whether a prolonged service code (+99354-+99355, Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond  he usual service ...) would be appropriate in addition to the E/M and chemotherapy administration codes. For prolonged service codes, the physician's additional face-to-face time must exceed the E/M code definition's typical visit time by 30 minutes or more, says Kelly C. Loya, CPC-I, CPhT, senior consultant with Los Angeles-based Sinaiko Healthcare Consulting Inc.

Example: The oncologist documents a 70-minute visit and the reason this patient required additional time. The medical necessity level for the visit meets 99214's criteria. This level E/M visit typically requires "25 minutes faceto-face with the patient and/or family," according to the code's descriptor. In this example, the 70 minutes spent is 45 minutes more than the typical time requirement of 99214, so this visit would be eligible for an additional prolonged service code. Report +99354 (...first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]) with 99214-25 and the infusion code(s). Adding +99354 ($93) to 99214 ($99) will nearly double your E/M reimbursement, based onMedicare's national rates.

Be sure to watch for adverse reaction cases that qualify for critical care codes. "If the patient already had a physician visit prior to the chemotherapy session and experienced a life-threatening adverse reaction to the drugs, the physician can bill for a critical care service [99291, +99292, Critical care, evaluation and management of the critically ill or critically injured patient ...] in addition to the visit if the physician's work involves at least 30 minutes of direct face-to-face involvement managing the patient's life-threatening condition," the MLN Matters article states.

The 30 minutes of critical care time that 99291 (...first 30-74 minutes) requires do not need to be continuous, advises Parra. And remember that CPT doesn't require an intensive care or emergency department setting for 99291 and +99292 (... each additional 30 minutes [List separately in addition to code for primary service]), she adds.

Example: A patient has a reportable pre-chemo 99213 E/M visit and during the infusion suffers a life-threatening reaction to the drugs. The oncologist spends 35 minutes providing critical care. You should report the infusion admin code(s), 99213-25, and 99291-25. For 99291, Medicare's national non-facility rate is roughly $258, so you want to be sure to catch legitimate critical care coding opportunities. (See "Excel at Critical Care Coding by Mastering Include/Exclude Rules" on page 12 for more information).

Resource: You can download the article from www.cms.hhs.gov/MLNMattersArticles/downloads/SE0462.pdf.