Oncology & Hematology Coding Alert

Oncology physicians that usually jot down phrases such as normal, negative, and no problems found to show they examined a body system need to beef up their documentation to ensure they get paid for the level of evaluation and management (E/M) services they deserve, according to Cindy Parman, CPC, CPC-H, principal at Coding Strategies Inc., a medical coding consulting firm in Dallas, Ga.

Mike Lewis, healthcare consultant with Mathieson Moyski Seler & Co., a Wheaton, Ill.-based accounting firm that provides reimbursement consulting, says, Documentation is the key to avoiding missed payment opportunities under current exam criteria and will be a greater challenge under new, more detailed criteria.

In the January issue of Oncology Coding Alert (Five Tips for Maximizing Pay up During Initial Cancer Diagnosis Appointment, on page 5), we examined how poor documentation of patient history can limit coding for higher levels of E/M services, such as 99205 (office or other outpatient visit). History is one of the three key components that determine the level of service, in addition to examination and medical decision-making. Failure to properly document any one of the three can lead to incorrect billing or having to bill for lower levels of service.

Even if physicians properly document detailed and comprehensive histories, they also must meet the documentation requirements for detailed and comprehensive examinations before they can successfully bill for level four or level five services. Poor examination documentation, like poor history documentation, will result in having no choice but to code for lower level E/M services than were performed.

Create Better Documentation Habits

Lewis suggests that the patient chart should have a heading that states examination to provide a clear indication that the information written below the heading reflects the examination of the patient.

Physicians often forget to make notations in the patient record to support the medical necessity of performing a detailed or comprehensive exam. The physician must remember that not all medical conditions will support a level four or a level five E/M, Lewis says. The key is the severity of the patients chief complaint. Unfortunately, the physician listens to the patient describe the problem, but then often writes down only minimal notes regarding the chief complaint. Without more definitive notes an auditor cannot see the medical necessity of a level four or five exam and will reduce the E/M to a lower level.

Lewis also reminds oncology physicians not to forget to include notes about the constitution of the patient, such as general appearance. The physician usually observes the patients general appearance but often neglects to write it in the notes unless it is a negative comment. For an exam to be a detailed exam, the physician needs to document at least five additional body areas or organ systems in addition to the affected body/system area, Lewis says. Documenting constitution provides an additional body area.

I recommend physicians develop an examination template with all 20 body areas/organ systems. This provides a ready reference that facilitates documenting all relevant parts of the exam, and makes a record that will keep an auditor from missing any part of the exam in the chart, he adds.

The need for a template is highlighted once oncologists understand how many things they are required to document under new exam criteria. Each of the 15 areas has two to seven elements that HCFA wants physicians to consider in their exam. The number of areas and elements will determine the level of the exam. According to Parman the levels will be determined as follows:

Level 1 One to five elements noted in the patient
record;

Level 2 or 3 Six or more elements noted in the
patient record;

Level 4 Two elements in six organ systems or 12
elements in two or more organ systems;

Level 5 Perform all elements and document two
elements in at least nine organ systems.

New Exam Criteria

According to the CPT, a detailed exam is defined as examining at least seven body systems and a comprehensive exam calls for eight body systems.

The 1997 exam criteria, which was proposed for required use by the Health Care Financing Administration (HCFA), asks physicians to address specific elements of each body system. Although mandated usage of the new criteria was postponed, HCFA gave physicians the option to use them.

Parman says physicians objected to the new criteria, which led HCFA to consider changes. Parman, who is a faculty instructor for the American Medical Association, says HCFAs changes are likely to be minimal and that physicians will be faced with having to incorporate 1997 exam criteria as early as 2001. Without taking new exam criteria into consideration, Parman says oncologists should make the following two changes to their exam documentation habits:

1. Avoid vague language. Chest normal doesnt tell the story of the body system exam. Include an exam description, such as inspection of breasts shows no masses, lumps or tenderness

2. Eliminate use of cloned notes. This is a particular
pet peeve of Medicare payers and auditors, Parman
says. Although it simplifies the dictation process,
the result is the exact same wording in every chart
despite patients differences in age, sex and condition.

The 1997 guidelines give oncologist two options, says Lewis, the general multi-system exam guidelines, or a single-system hematologic/lymphatic/immunological exam. Either option requires significantly more documentation than the pre-1997 guidelines.

Lewis advises physicians to use the multi-system exam to ensure they are documenting under pre 1997 guideline requirements. A detailed exam under the single-system guidelines requires at least 12 elements; a comprehensive exam requires the physician to document every element in the required body area/systems and at least one element in the remaining systems. (Please refer to the body-system tables in the next column.)

It will be challenging to keep up with required elements of each body system, and that challenge will be compounded by the additional detail required under new exam criteria. Language in the patient record must illustrate that each required element was addressed. For example, an examination of the neck area is often described in physician notes as normal if nothing abnormal is found. Parman points out that for now that is acceptable, but under the multisystem examination, the neck has two elements HCFA wants physicians to consider:

1) examination of neck for masses, overall appearance, symmetry, tracheal position and crepitus;

2) examination of thyroid for enlargement, tenderness,
and mass.

Under these requirements normal or negative are no longer acceptable, says Parman. Instead, physician notes should say something similar to: No masses found, neck is symmetrical and tracheal position is good.

Doctors have to get used to these new requirements if they want to score above a level two.