Oncology & Hematology Coding Alert

Detailed questioning is crucial to correctly coding for evaluation and management (E/M) services because the amount of documentation done drives reimbursement.

Therefore, oncology practices should treat patient charting as an ally to secure the highest levels of reimbursement for E/M services (99201-99215), advises Cathy Klein, LPN, CPC, senior consultant with Indianapolis-based Health Care Economics, Inc. If its not documented, it didnt happen, Klein warns.

Patients need to be closely questioned during their initial visits about:

1. Family history. This includes the health status or cause of death of parents, siblings and children; specific diseases related to problems identified in the chief complaint or history of present illness; diseases of family members that may be hereditary.

2. History of present illness. While this may be provided upon referral, practitioners need to be sure a chronological description of the patients cancer is in the record.

3. Past history. The chart should include a review of the patients past illness, injuries and treatment. Detailed information about prior major illnesses and injuries; prior surgeries and hospitalizations; current medications; allergies, age appropriate immunization status and dietary habits.

4. Social history. Physicians need to document past and current activities including: marital status; current and past employment; drug, alcohol and tobacco use; level of education; sexual history; and other relevant social factors.

5. System review. Physicians need to take inventory of 10 major body systems or pertinent systems to help define the problem, clarify the differential diagnosis, identify needed testing, or serve as a baseline for systems that might be affected by possible management options. A statement such as all other systems reviewed can be substituted for those systems that have negative findings.

New Patient, New Problem, Four Questions

I always recommend to physicians that they have a well-documented history of the present illness (HPI) when seeing a new patient or addressing a new problem, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in North Augusta, S.C. She recommends asking these four questions at the minimum:

1. How long have you had the problem?
2. How has it changed during the course of that time?
3. What are your signs and symptoms?
4. Has anything been tried so far? If so, what was the outcome?

Callaway-Stradley says documenting the answers to these questions in conjunction with the past, family and social history, and the review of systems, should provide enough history to support any level of service.

Its key that there be background data in order to bill, Klein says. The basic format for E/M services recognizes seven components, six of which are used in defining the levels of E/M services, according to Alan Ertle, MD, MPH, The Corvallis Clinic, P.C., in Corvallis, Ore. The CPT lists the key components as:

History;
Examination; and
Medical decision-making.

But because much of this responsibility falls on physicians and nurses who tend to spend more time with the patient than the patients record, a cursory history may be all that gets documented.

For example, an oncologist handling a prostate cancer referral may fail to review other body systems, such as the ears, nose and throat, in focusing on the problem area during the initial visit (99201-99205, outpatient services, new patient).

They [oncologists] are singularly focused [on the] cancer, explains Cindy Parman, CPC, CPC-H, principal of Dallas, Ga.-based CSI Coding Strategies, a consulting firm that advises radiation oncology practices. They focus on what they need to know in order to treat the patient. While this is good medicine, its bad from a documentation standpoint.

Using a Template

The solution to collecting solid patient history data, says Klein, is to use a template for the questionnaire that prompts practitioners to ask all the right questions. Question off the top of ones head may not draw a complete picture of a patients history, Klein says. Alternatively, patients could fill out a questionnaire before the doctor sees them. Payers will require the physician to indicate in the patient record that the patients self-reported information was reviewed.

Inadequate patient histories can spell the difference between reimbursement at the higher-paying Level 5 E/M rate (99205, office or other outpatient visit) and the lower- paying Levels 1-4 (99201-99204, office or other outpatient visit, new patient) services. The lowest level of service involves at minimum these three E/M components, according to CPT 2000:

A problem focused history;
A problem focused examination; and
Straightforward medical decision-making.

The physician spends typically 10 minutes in face-to-face time with the new patient during a Level 1 (99201) visit. However, a Level 2 (99202) E/M visit typically involves 20 minutes of a physicians face-to-face time with the patient and the record of the patients medical history is described as expanded by CPT. A Level 3 (99203) visit with a new patient is more complex and typically involves not only 30 minutes of the physicians time, according to the CPT, but:

A detailed history;
A detailed examination; and
Medical decision-making of low complexity.

In order to get reimbursed for the higher-paying Level 4 (99204) and Level 5 (99205) E/M new-patient visits, a complete past, family and social history needs to be taken and documented carefully in the patients records, Parman explains. I tell my practices to always do a complete exam, she says.

Level 4 and 5 visits require documentation indicating that a comprehensive history was taken and a comprehensive examination was conducted. The symptoms presented in a Level 4 visit involve medical decision making of moderate complexity, while the Level 5 requires medical decision making of high complexity, according to the CPT manual. If these key components are not present or are not properly documented in the patients records, the visit will be reimbursed by the carrier at a lower E/M level of service.

Physicians also may simply forget to make the proper notations about the questions asked in the patients record, Parman says. For example, the physician may forget to note he evaluated the patient-reported systems review. In these instances, physician education can be the cure, she says. It might be a matter of sitting down with the physician and saying, Look, these are Level 4 visits that we have had to bill at Level 2 because you didnt include these pieces of documentation, Parman says.