Oncology & Hematology Coding Alert

Making rounds through a chemotherapy area to answer patients questions and to address their concerns certainly can help improve patient satisfaction. But, oncologists still must gather patient history, perform an exam and show complexity of medical decision-making before billing the encounter as a patient visit.

The December Oncology Coding Alert (Four Often-overlooked Billing Opportunities) advised oncology physicians to code 99212 or 99213 (office or other outpatient visit) for each patient they encounter during their chemotherapy rounds.

One expert warns, however, not to take the advice too literally and to meet all the requirements of a visit before billing Medicare and others for an established-patient visit. You must still perform all pieces of a visit, says Elaine Towle, CMPE, practice administrator for New Hampshire Oncology-Hematology, an oncology practice in Hooksett.

Code 99212 reflects a level-two visit. It requires a problem-focused history, a problem-focused exam and straightforward medical decision-making. Code 99213 reflects a level three visit. It requires an expanded history, an expanded problem-focused examination, and low-complexity medical decision-making.

In general, physicians spend 10 to 15 minutes of face-to-face time with the patient or the family. Counseling and coordination of care with other providers or agencies also is part of the service covered by E/M codes.

The same Oncology Coding Alert article advised physicians to code 99354 (prolonged physician service in the office or other outpatient setting . . . first hour) and 99355 (each additional 30 minutes) for lengthy visits even if the physician did not spend the total time in front of the patient.

Towle warns that physicians shouldnt stray from the literal meaning of face-to-face. I dont think its open to interpretation, she says. The physician has to be present in the office setting with the patient. A prolonged visit might include discussing modifications to the care plan or counseling a patient about treatment options. Time outside of the exam room while a nurse is with the patient does not count as face-to-face time.

According to the CPT, 99354 and 99355 should be used when direct, face-to-face contact with the patient on a given date is prolonged and beyond the usual service, even if the contact is not continuous.

But a CPT 2000 clinical example muddies the definition of face-to face. The example allows the use of 99354 and 99355 for a patient whose condition requires intermittent physician face-to-face care over a two-hour period.

The question is whether physicians must separate actual face-to-face time from time spent outside the patients presence, or are allowed to bill from start to finish as long as some face-to-face time is included. Towle says physicians should opt for the more conservative route and use 99354 and 99355 to bill only for the time they are in direct contact with the patient.

Editors note: The CPT provides codes 99358 and 99359 (prolonged evaluation and management services) to account for prolonged service without direct, face-to-face patient contact. Towle says that in spite of the codes being available, Medicare does not recognize non-face-to-face prolonged service as reimbursable.