Oncology & Hematology Coding Alert

Check your documentation for the oncologist's role before you code

If you think oncology practices don't have to bother with supervision requirements, think again. You shouldn't report a number of imaging services crucial to cancer treatment unless you-ve verified that the physician provided either general, direct or personal supervision.

If you have to code the technical component for any of the following codes, be sure you double-check the supervision requirement:

Read Up on Requirements

In most cases, if the physician doesn't directly provide all services a patient receives, you must nevertheless document a minimum level of physician supervision. The extent to which the physician must supervise nonphysician staff varies by procedure. CMS has designated three principle levels of physician supervision:

Level one: general supervision. -General supervision means the procedure is furnished under the physician's overall direction and control,- says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. -But the physician's presence is not required during the procedure.- The physician must order the test and document medical necessity but does not have to be in the office at the time of the performance of the test, she says. The physician is responsible for training the people who do the tests, ensuring that they remain current with their education, and maintaining the testing equipment.

You need general supervision for 76950-TC.

Level two: direct supervision. This means that in the office setting the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the procedure. The physician doesn't need to be present in the room during the procedure.

Verify direct supervision for 76370-TC and 76873-TC.

Level three: personal supervision. In this case, the physician must be present in the room during the procedure to offer hands-on assistance and direction or to directly perform the service.

For a level-three service, the physician -must be physically in the room with the patient and the NPP [nonphysician practitioner] providing the service. He or she cannot be across the hall with another patient or making phone calls at the front desk,- Mac says.

Double-check the record for personal supervision for 76965-TC.

Tip: You can find the required supervision levels for all codes by looking to column -Z- (-Physician Supervision of Diagnostic Procedures-) of the Physicians Fee Schedule database, available at www.cms.hhs.gov/physicians/mpfsapp/step0.asp or www.cms.hhs.gov/physicians/pfs/default.asp.

Seize the Chance to Prove Doctor's Role

CMS is vague about how to demonstrate you-re not breaking the rules. The policy says, -Documentation maintained by the billing provider must be able to demonstrate that the required physician supervision is furnished.- Translation: You and your physician must make sure you have thorough documentation in place.

What to do: Meet with your physicians to nail down a set process to follow when they document supervision, says Deborah Chudzik, vice president and senior consultant with Independence, Ky.-based Neltner Billing and Consulting Services, which specializes in radiation and medical oncology.

Then, if the doctor fails to follow the process, you know where he skimped in the documentation and can bring it to his attention, Chudzik adds. -Coders have a unique opportunity because they-re seeing the codes and also viewing the documentation,- she says.

Motivation: Don't view documentation as something to be feared in case of an audit, Chudzik says. Instead: Let the physician know that documentation is his opportunity to prove the value of physician services, which could be key the next time payers are determining reimbursement, she says. -Coding and documentation go hand in hand to demonstrate what they provide.- This effort is especially important in medical oncology, where the focus on drug payment means the doctor's services often go uncompensated.

To shore up your documentation, follow these tips:

- Make sure the employee file of any nonphysician practitioner who performs general (level-one) supervision diagnostic tests contains a note indicating that he is fully trained for the procedure. Keep track of CMEs and CEUs to prove he's meeting requirements.

- Place a printout of the procedure results in the patient's chart.

- For procedures requiring personal (level-three) supervision, make sure the progress notes contain a comment by the supervising physician to document his presence.

Remember: Even if your code's supervision requirement is -9: Does not apply,- you may need to check that providers are following incident-to rules, Chudzik says. Example: Chemotherapy administration codes sport a -9- for supervision. If an NPP not allowed to supervise admin provides the service, be sure you meet the following incident-to rules:

-  the physician performed an initial evaluation and prescribed a plan of treatment

-  the NPP (such as an oncology nurse) is employed, leased, or contracted by the practice

-  a physician is present in the office suite to supervise (not necessarily in the same room, but immediately available).

Caution: If the physician isn't in the office and the NPP's scope of practice allows him to supervise chemotherapy administration, report the service under the NPP's provider identification number. And as always, check with your payer. Many don't accept incident-to for NPPs. Many managed-care payers, for example, want your NPPs credentialed and ask you to report anything NPPs do under their ID number.