Oncology & Hematology Coding Alert

Question: I want to be sure I'm reporting PQRI measure 72 correctly for 2011. We use claims based reporting. As an example, a 67-year-old patient has been diagnosed with a stage IIIA malignant neoplasm in the descending colon. He presents to our office as a new patient (level-5 office visit) referred for chemotherapy following surgery for the tumor. The oncologist prescribes the FOLFOX regimen. How should we report this case?

Answer: Physician Quality Reporting (CMS dropped the "I," which stood for "Initiative") requires a multitude of elements. First, check to be sure your patient is eligible. Measure 72 requires the patient:

• To be 18 or older (your patient is 67)
• To have a colon cancer diagnosis that falls under 153.x or V10.05 (Personal history of malignant neoplasm; large intestine) (your patient's diagnosis is 153.2, Malignant neoplasm of colon; descending colon)
• To present for a new patient (99201-99205) or established patient (99212-99215) E/M visit (your patient presented for a visit that warranted 99205, Office or other outpatient visit for the evaluation and management of a new patient ...).

Once you've determined the patient is eligible, choose the appropriate Category II code(s) with any applicable modifiers. Your patient was referred for adjuvant chemotherapy and the oncologist prescribed that chemotherapy, so you should report 4180F (Adjuvant chemotherapy referred, prescribed or previously received for Stage IIIA through Stage IIIC colon cancer) for this measure.

Don't miss: For the case you describe, you should report 3388F (AJCC Colon Cancer Stage III, documented), as well.

So your claim should include 99205, 4180F, and 3388F, with ICD-9 code 153.2.

Note that you should report the measure at least once during the reporting period for all patients you see during the reporting period who have colon cancer. Be sure to read the official CMS documents on your coding options for this measure. Download the 2011 Measure Specification documents here: www.cms.gov/PQRI/15_MeasuresCodes.asp.