Oncology & Hematology Coding Alert

... but you may be able to support a higher-level E/M - and get paid

The 2004 Medicare Physician Fee Schedule now prohibits oncology practices from billing 99211 with drug administration codes (96400, 96408-96542; 90780-90788), but the new rule may not hurt your reimbursement.
 
In the fee schedule, which took effect Jan. 1, CMS added 0.17 RVUs to the administration codes. The increase equals the RVUs for E/M code 99211 (Office or other outpatient visit for the E/M of an established patient ...), and therefore, Medicare considers 99211 included in the codes when billed on the same day, according to the fee schedule.
 
Also, because the government includes the lost 99211 RVUs in the drug administration codes, you shouldn't lose much reimbursement and may even see revenue increases.
 
Oncology practices' reimbursement should improve if they report an administration code, such as 96408 (Chemotherapy administration, intravenous; push technique), instead of 99211, says Arlee Session, corporate clinical executive of Forum Health's CancerCare in Youngstown, Ohio.
 
You can bill 96408 multiple times if the physician uses multiple drugs, but you can submit 99211 only once per visit, he adds.
 
Most oncology coders refer to 99211 as a "nurse-only visit." Coders would assign 99211 when the nurse provided a low-level office visit in addition to chemotherapy services. The nurse must have performed an evaluation separate from the chemotherapy.
 
For example, during a patient's chemotherapy treatment, the patient complains of nausea. The nurse administers antiemetics, and the patient recovers. Prior to the 2004 Physician Fee Schedule, you could have submitted the appropriate chemo code (for example, 96408), as well as 99211.
 
Now, however, you couldn't use 99211 and 96408 together under any circumstances.
 
But Medicare still allows physicians to bill other offices visits (for example, 99212-99215) along with codes 96400-96542 and 90780-90788. But you have to attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.
 
Some oncology practices may want their oncologists to personally evaluate a patient during chemotherapy services, so they can bill a higher-level E/M, such as 99212 (Office or other outpatient visit for the E/M of an established patient ...), says Lisa C. Wood, office manager at Cancer Center of the Piedmont in Danville, Va. When the physician sees a patient, you can usually submit 99212 or 99213 instead of 99211.
 
You should report a higher-level E/M visit as long as the visit is medically necessary and you can support the E/M code with appropriate documentation, says Tracy Sweat, a certified professional coder at Piedmont Oncology Specialists in Charlotte, N.C. Conditions that warrant a physician evaluation are common with cancer patients. The treatment and disease's severity causes health problems, and most cancer patients have co-existing health problems, she says.
 
Take, for example, the chemotherapy patient who develops nausea with vomiting. If the oncologist, not the nurse, treated the patient, then physician presence alone would justify your billing 99212, coding experts say. The documentation should include the proper ICD-9 code (787.01, Nausea with vomiting) and note that the physician personally treated the patient.