Oncology & Hematology Coding Alert

Recent News Item:
In the last days of 1999, Tipper Gore, the wife of Vice President Al Gore, underwent a thyroid lobectomy to remove a tumor that physicians later determined was not cancerous. The treatment and services that she received highlight some of the complexities of coding for similar services, including documentation of evaluation and management (E/M) office visits and unbundling services, says Susan Turney, MD, FACP, medical director for the Marshfield Clinic in Marshfield, Wis.

Typical Clinical Scenario:
According to news accounts, Gore originally complained of neck pain that she thought was the result of an exercise injury. After an examination, physicians discovered a growth on the right side of her thyroid, the butterfly-shaped gland that wraps around the front of the windpipe and produces hormones that regulate body functions. After a battery of noninvasive tests came up inconclusive, a two-hour surgery was performed to remove the tumor and a portion of Gores thyroid.

Coding Implications:
The physician who examines the patient after a growth is detected can bill a new patient office visit (99201-99205), or an established patient visit (99211-99215).

Another option that may be available to the physician is to bill for an office consult (99241-99245). In order to bill for the consult, however, the consulting physician must receive and be able to document a written or verbal request for the examination from another physician, the consulting physicians opinion and the services ordered and performed, and the report written to the physician who requested the consult.

While billers have several choices, the common element to E/M services (99201- 99499) is the proper documentation of three key componentspatient history, patient exam, and the level of complexity to the medical decision-making.

Once we have established that the visit was not a consultation, we would then need to determine if the patient was a new or established patient, says Turney, who oversees reimbursement and payer policies for all of Marshfield Clinics physician practices, including its oncology practices. The level of service would be determined by the history, exam, and decision-making.

Billing Diagnostic Tests

To determine whether the discovered tumor is malignant, a series of tests, such as the fine-needle aspiration (88170, fine needle aspiration with or without preparation of smears; superficial tissue; e.g. thyroid, breast, prostate) done on Gore, are to be expected. Procedures such as nuclear medicine thyroid imaging (78010, thyroid imaging; only), and a diagnostic ultrasound;76536; echography, soft tissues of head and neckthyroid, parathyroid, parotid B-scan and/or real time with image documentation) would likely precede the fine needle aspiration. Use of the B-scan implies a two-dimensional ultrasonic scanning procedure with a two-dimensional display.

In Gores case, the tests were unable to determine whether the growth on her thyroid was malignant, and the decision to perform surgery was made. In similar cases, the surgeon to whom the patient is referred can bill for a consult for the initial visit (99241). Like the first physician, the consulting physician has five levels of service to choose from.

If the surgery is performed on the same day as the consult, the surgeon should use modifier -57 (decision for surgery) with the appropriate E/M service code for the visit to avoid having the examination bundled into a global surgery code, Turney says. The surgery itself should be coded as 60210 (partial thyroid lobectomy, unilateral; with or without isthmusectomy).

Once the growth is removed and sent to a pathologist to determine whether the tumor is malignant, the pathologist would assume billing responsibility. The pathologist can bill 88307 (level V surgical pathology, gross and microscopic examination), for the examination of the removed tumor.

Turney says if the patient has no complications, follow-up E/M visits may be billed once the global period for surgery has passed. Check with specific carriers to determine the global period for this surgical procedure.