You Be the Coder:
Chemo Following Hysterectomy
Published on Mon Jul 01, 2002
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: A physician performed a hysterectomy on a Medicare patient with ovarian cancer. About three weeks later the same patient began chemotherapy in the hospital's outpatient infusion unit. The physician monitored the patient during the initial chemotherapy session, which we reported with an observation code. We assigned the V code for chemotherapy to demonstrate medical necessity. Medicare denied the observation claim, noting the visit is part of postoperative care. I resubmitted the claim, using modifier -58 because it was part of a staged protocol, but it was still denied. How should I code this?
New York Subscriber
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Answer: In situations like this, precise diagnosis coding makes the difference between payment and denial. The original surgical procedure (e.g., 58150, Total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]) includes an entire surgical package, which defines specific services that are considered part of the procedure. Both CPT and Medicare recognize these packages. When setting the fee schedule for services, Medicare factors surgical package components into the final payment amount. Services that are always covered within the global service include:
local infiltration, metacarpal/metatarsal/digital
block or topical anesthesia
subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical)
immediate postoperative care, including dictating operative notes, talking with the family and other physicians
writing orders
evaluating the patient in the postanesthesia recovery area
typical postoperative follow-up care.
However, complications, exacerbations, recurrence or the presence of other diseases or injuries requiring additional services are not included in the surgical package and should be separately reported. Chemotherapy following surgery falls into this category. Two diagnosis codes are reported to ensure that Medicare (and other payers) recognize that the chemotherapy is distinct from the surgical procedure. Code V58.1 (Encounter for other and unspecified procedures and aftercare; chemotherapy) should be used as the primary diagnosis, and the appropriate cancer diagnosis (e.g., 183.0, Malignant neoplasm of ovary and other uterine adnexa; ovary) should be secondary.
Do not use modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) on any of the CPT codes. Not only is it incorrect, it implies that the chemotherapy truly was part of the initial procedure.
And you should recognize that payment for the observation service will depend on several factors because the patient was seen in a hospital's outpatient unit.
If the patient was formally admitted to the hospital as an observation patient or as an inpatient, you may use codes 99234-99236 (Observation or inpatient hospital care). But Medicare allows this service to be reported only when patients are admitted to and discharged from observation on the same calendar date, and when the patient remains under observation for at least eight hours.
If a Medicare patient remains in observation for fewer than eight hours, but is nonetheless admitted to and discharged from observation on the same calendar date, the oncologist assigns only an observation admission code (99218-99220, Initial observation care). No code for discharge from observation (99217) would be reported. CPT doesn't require observation stay to be eight hours or more to report codes 99234-99236.
Alternatively, if the nursing staff is not employed or contracted by the physician, but the patient sees the physician for a review of systems and determination of chemotherapy orders, the appropriate E/M code could be used based on the level of service (99212-99215). If the patient does not see the physician and is treated by nurses employed by another entity such as the hospital, the physician cannot bill for any services.
In yet another situation, the physician might employ or contract the nursing staff who administers the chemotherapy. If the patient sees the physician for a review of systems (ROS) and determination of chemotherapy orders, the appropriate E/M code should be used based on the level of service provided (99212-99215). In addition, the practice may bill for the chemotherapy drugs and the appropriate procedure codes for the chemotherapy administration if the drugs were purchased and supplied by the practice, e.g., 96410, Chemotherapy administration, intravenous; infusion technique, up to one hour; and +96412, infusion technique, one to 8 hours, each additional hour (list separately in addition to code for primary procedure).
The coding changes when only the employed/contracted nursing staff interacts with the patient. For instance, if the nurse performs the ROS and the laboratory result review, and communicates this to the physician and obtains orders for the chemotherapy, you may assign 99211. Codes for the chemotherapy drugs and the appropriate procedure codes for the chemotherapy administration should also be reported. | |
