Oncology & Hematology Coding Alert

Forgetting the 50 percent rule shortchanges your practice

Downcoding a 99214 service to a 99213 can lose your practice $30 per encounter. Simply checking off E/M code requirements won't save you from this snafu. You also have to look for chances to report a higher-level E/M based on counseling time.
 
How it works: If your oncologist doesn't complete all of the requirements for an E/M service, you may still be able to report a high-level code if he spends more than 50 percent of the time counseling and coordinating care, says Linda Gledhill, MHA, senior associate with oncology consulting firm ELM Services Inc., based in Rockville, Md.

CPT guidelines stress that the physician must clearly document the extent of counseling and the time involved to code by time.

Start here: For most E/M codes, CPT lists the time the oncologist usually spends rendering the service, called the -reference time.- For example, for established patient code 99214, CPT states, -Physicians typically spend 25 minutes face-to-face with the patient and/or family.-

How to use the reference time: Suppose your oncologist completes an expanded problem-focused history and examination on an established patient (enough for a level-three visit), but spends a total of 30 minutes with the patient and documents that he spent 20 of those minutes providing counseling. 

Because more than 50 percent of the visit consists of counseling, you can use the total time to determine the level of service. In this case, you could report 99214 for the visit.
 
Document Start and Stop Times If you choose an E/M code based on time, the oncologist must document the total visit minutes and total counseling/coordination of care minutes to prove that counseling dominated the visit, according to CPT Assistant, August 2004. The oncologist must also summarize the content of the counseling, indicating, for example, that the patient was anxious about his diagnosis and treatment and that the oncologist spent time explaining the treatment, reviewing treatment literature, and putting the patient in touch with outside support services.

Beware: Time that the oncologist spends taking the patient's history or performing an examination does not count as counseling time. Time he spends documenting the service separate from the face-to-face encounter also isn't part of the total time. Your payer may have other rules you need to know, too. Example: CMS states that time-based visits include time the physician spends face-to-face with the patient, not the patient's family.