Oncology & Hematology Coding Alert

In the second-quarter issue of Florida Medicare B Update, which came out in February 2002, oncology practices were scolded by the state's Medicare medical director, Sidney R. Sewell, MD, who singled out billing of 99211 (Office or other outpatient visit) with chemotherapy services as a key contributor to the state's higher-than-average billing of the level-one office visit code. Sewell said that if Florida providers billed CPT 99211 at the same rate as the national average, Florida Medicare would save more than $10 million a year. Specifically, Sewell was concerned with chemotherapy-related office visits that oncology practices were billing as "incident to" visits that included inserting a catheter, setting up an IV, monitoring for adverse reactions, and dealing with nausea. None of these, he wrote, satisfies requirements that would deem 99211 as a "significant and separately identifiable" service. For oncology practices to appropriately separate 99211 as incident to physician services, there must be a problem outside of preparing for scheduled chemotherapy treatment that requires medical decision-making.

In addition, Sewell said the phrase "may not require the presence of a physician" in the CPT descriptor for 99211 causes doctors to mistakenly assume that they do not have to be in the office suite to bill for "nurse-only" visits. He urged Medicare providers to review the details of billing 99211 to reduce payment errors.

Sewell says his views do not represent a new policy for Florida Medicare providers to follow, nor does it mean that a mass review of claims is under way or being planned.

While his comments are directed toward Florida practices, oncology in particular, it is not unreasonable to assume that medical directors and Medicare carriers around the country share his view. ASCO Argues for 99211 Coding experts agree with Sewell that physician presence in the office suite is required to bill 99211. However, some believe that 99211 should be used to report services related to the chemotherapy visit.

"As long as the nurse takes good notes, including recording any complaints and an assessment of the patient's condition not just the fact that the patient was hooked up for an infusion 99211 is appropriate, and practices should be able to bill it," says Dianna Hofbeck, president of Northshore Medical, a coding consulting and billing firm in Atlantic City, N.J. Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hookset, agrees with Hofbeck. "Any knowledgeable nurse will conduct an assessment of the patient prior to chemotherapy administration to check for toxic side effects from previous chemotherapy treatment," Towle says. "This assessment, as long as it is thoroughly documented, should be enough to bill 99211."

The American Society of Clinical Oncology's (ASCO's) Practice Tips for the Practicing Oncologist also [...]