Oncology & Hematology Coding Alert

Why your practice must recommend an appropriate fee

Just because the oncologist administered a form of chemotherapy that has no CPT code, you shouldn't give up on accurate coding to get the pay you deserve. When the oncologist performs this type of service, your only option is to report an unlisted-procedure code. Here's how: 1. Describe the Procedure in Plain English If you report an unlisted-procedure code (for example, 96549, Unlisted chemotherapy procedure), you should submit a full procedural report to describe the procedure or service. But to get fair reimbursement, the procedure notes alone won't be enough. You should include a separate report that explains in simple, straightforward language exactly what the oncologist performed.

"There's no 'standard' fee for an unlisted-procedure code," says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. "Insurers consider claims on a case-by-case basis and determine payment based on the documentation you provide. Unfortunately, claims reviewers, especially at lower levels, do not have a uniformly high level of medical knowledge, and physicians don't always dictate the most accessible notes." Submit Great Documentation, Collect Great Pay The oncology coder should act as an intermediary between the oncologist and the claims reviewer, providing a description of the procedure in layman's terms.

"If the person making the payment decision can't understand what the physician did, there's not much chance that the reimbursement you receive will properly reflect the effort involved," says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Brick, N.J. Be careful to avoid or explain medical jargon and difficult terminology. And, if appropriate, you may include diagrams or photographs to better help the insurer understand the procedure.

For example, under Medicare's current policies, you may bill for the process of image fusion (that is, positron emission tomography/computed tomography fusion imaging) as a service over and above the charge for the exams from which the physician obtained the fused images. Medicare now has no policy on the coding or reimbursement of fusion imaging, which is the anatomic localization of PET (positron emission tomography) or SPECT (single photon emission computed tomography) studies performed with CT (computed tomography). And no CPT code describes the process of image fusion.

When the radiation oncologist clinically indicates the studies, and if a physician provides separate interpretations, you may report the PET, SPECT, CT and anatomic localization studies separately. You should code the CT study separately from the anatomic localization study only when the physician performs a complete study and demonstrates medical necessity. The American College of Radiology (ACR) recommends using 78999 to represent this image fusion, since [...]