Oncology & Hematology Coding Alert

Oncologists are in CMS’ hot seat for these services — don’t be a statistic.

Billing subsequent hospital care visits may seem simple, but recent CMS data has indicated that for oncology practices, it may be more complex than you think.

Background: In last month’s issue (Vol. 19, no. 4), you read about the most egregious coding errors impacting oncology offices, according to CMS’s most recent Comprehensive Error Rate Testing (CERT) reports. The article offered examples on coding oncology-specific scenarios, but it was a different issue that piqued the attention of readers.

Several subscribers wrote to Oncology and Hematology Coding Alert asking for elaboration on the citation in the article that mentioned oncologists’ startling 17.3 percent error rate for subsequent hospital visits.

“We aren’t there in the hospital, so we aren’t sure what our oncologist is doing wrong, but his documentation doesn’t always support the codes he reports,” wrote one reader. “Actually, in some cases, he’s coding too low for what he documented.”

If you’re in the same situation as this coder, read on for oncology-specific subsequent hospital care visit tips that can ensure you’re always coding properly for these common services.

Are You Among Those Billing Improperly?

The subscriber who wrote in to express her physician’s potential coding errors indicated that her oncologist documents enough to warrant higher-level subsequent hospital care codes than he’s reporting. As long as everything he documents is in the record and medically necessary, chances are that this practice is leaving money on the table.

Here’s why: Because 99231 pays about $33 less than 99232, downcoding these claims just 10 times a month could cost your practice $3,960 per year.

Keep in mind: The CERT reviewers aren’t the only entities looking at oncologists’ subsequent hospital care claims. Less than a year ago, Part B MAC Noridian Medicare said that it has been reviewing charts for code 99233 when billed by hematology and oncology specialists. With these reviews coming at your practice from all sides, it’s more important than ever to work with your physicians to ensure that coding and documentation are on the level for these services.

1. Learn Coding Levels, Then Review Charts

To determine whether your practice can increase your inpatient coding levels, make sure you know what constitutes each service level before you review the documentation, coding experts say.

You can use the following basic guidelines for the three subsequent hospital care levels as a good starting point for physician education. The following codes apply to subsequent hospital care, along with the requirements for each code:

• 99231 — ... problem-focused interval history; problem-focused exam; medical decision-making that is straightforward or of low-complexity …
• 99232 — ... expanded problem-focused interval history; expanded problem-focused examination; medical decision-making of moderate-complexity ...
• 99233 — ... detailed interval history; detailed examination; medical decision-making of high-complexity ...

Remember:  You need two of the three key E/M components (history, exam, and medical decision-making) to report subsequent hospital care services. So if your doctor records a problem-focused interval history but an expanded problem-focused exam and moderate complexity medical decision-making (MDM), you can report 99232 since both the exam and MDM meet the requirements for this code.

2. Bring Chart Review Results to Oncologists’ Attention

If your oncology practice routinely bills the same subsequent hospital care code, you should perform a chart review to ensure you’re accurately coding the visits, says Terri Orcala of Orcala Billing in Kansas City, Mo.

“Ask the doctor to send you a random sampling of the charts where he billed 99231,” she advises. “Scrutinize the files to determine whether the history, exam and medical decision-making levels meet the requirements for 99232 or 99233, and if so, sit down with him and explain the outcome.”

Another possible coding problem is when the physician reports 99233 one day, 99231 for the same patient the following day, and then returns to a 99233 charge the day after. Make sure the documentation explains why the patient’s condition necessitated different levels of care each day translating to a change in coding levels.

No matter what the outcome of your audits, you’ve got concrete evidence to speak with your physicians and explain exactly what they can improve upon to bring in the appropriate reimbursement and eliminate the time wasted dealing with denials and audits.

3. Look for Those All-Important “2 of 3” Components

Of the three E/M components — history, exam and medical decision-making — you must fully document two components meeting the level of the E&M code selected to justify use of each subsequent care code. If there is little or no documentation, then you need to change the code.

Typically, oncologists document the exam and medical decision-making components to fulfill CPT^®’s E/M requirement. If your physician performs and documents high-complexity medical decision-making along with a detailed exam, this supports a 99233. But if the documentation falls short on both of the other two elements and doesn’t justify the level of care using time as the key component, even if the doctor says he did more than what’s on paper, then it’s an appropriate time to go over the essentials of thorough documentation with all of the practitioners in your office.