Oncology & Hematology Coding Alert

A recent CMS transmittal clarifies a few of your E/M questions

The descriptor for 99211 tells you that your patient must be established for you to report this E/M code. CMS recently clarified the meaning of the terms -new- and -established- for E/M coding.

Here's what you need to know before reporting 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services):

Experts say the policy hasn't really changed, but CMS is explaining it differently, and the transmittal can provide a useful refresher course. According to CMS, someone is a new patient if none of your physicians have seen her face-to-face in the past three years.

In other words, if one of your physicians interpreted a patient's test results or did some other non-face-to-face service in the past three years, you can still consider that individual a new patient the next time she comes into the office, says consultant Devona Slater with Auditing for Compliance & Education in Leawood, Kan.

Also, CMS says it won't pay for any E/M services on the same day by physicians in the same practice and same specialty--unless you document that the visits were for unrelated problems.

Impact: Sometimes carriers won't pay for same-day E/Ms even when they-re for unrelated problems, but CMS is telling the carriers to pay for repeat visits as long as the patient presents for unrelated illnesses or injuries. Find the full details in transmittal 731, dated Oct. 28, 2005, at www.cms.hhs.gov/manuals/pm_trans/R731CP.pdf.