Oncology & Hematology Coding Alert

Oncology is a nursing-intensive specialty. A fair amount of care is given to patients outside of the view of a physician. Keeping track of nurse-provided services is crucial if practices want to get fair reimbursement for the entire course of a patients treatment.

The most accurate way to bill for a short, nurse-only evaluation and management (E/M) visit is to use code 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician).

A common practice among oncology practices is to provide follow-up care during chemotherapy treatment. The patient sees the physician on the first day of treatment, but usually follow-up care a brief review of systems, checking for chemotherapy side effects and then making the decision to proceed with the chemotherapy as ordered by the oncologist is handled during nurse-only visits. Unless any excessive or unexpected side effects occur and are reported to the physician, treatment continues without higher levels of E/M services.

According to CPT, code 99211 is reserved for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the CPT says, the presenting problems are minimal. Typically, five minutes are spent performing or supervising these services.

The time spent with the patient may vary with the needs of the patient, says Mary Mulholland, BSN, RN, CPC, reimbursement analyst in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

In oncology time is not as crucial a factor as the services, says Elaine Towle, CMPE, practice administrator with New Hampshire Oncology and Hematology, an oncology practice in Hooksett, N.H. Nurse-only visits may take longer than five minutes because of a series of services performed during the visit. For example, a nurse may check a patients vital signs, monitor side effects and flush ports. Although the time needed to complete all of the services may be longer than five minutes, 99211 is still the only appropriate code. Higher levels of E/M service call for longer service time, but require a physicians presence and that the key components of an E/M service be completed.

When the Nurse Notices a Change in Condition

There are instances, however, when a nurse-only visit changes into a higher E/M visit. If a nurse, in the course of his or her E/M service, notes an excessive or unexpected side effect and reports it to the treating physician, the characterization of the visit changes if the physician takes part in the visit.

For example, when a nurse discovers an abnormality, a new problem or an exacerbation of an existing problem, he or she must notify the supervising physician, says Towle. Because additional care falls outside of the physicians treatment plan that the nurse is following, any additional medication or care falls outside of the nurses authority.

Once the nurse alerts the physician to the patients new symptoms, the physician most likely would want to see the patient right away. If the physician subsequently provides an E/M service for this patient on the same date of service, only the physicians service would be reported, says Towle. The claim form must contain the medical necessity for the physicians services as demonstrated by the use of the appropriate ICD-9 diagnosis. No modifiers are necessary because the ICD-9 codes will identify the conditions treated during the visit.

Incident-to Guidelines Apply

Nurses who bill 99211 need to follow the incident-to guidelines set forth by the patients insurance carrier. Medicare specifies that practices billing incident-to must meet its requirements, which state that the physician must be on-site at the time of treatment, the physician must have seen the patient originally during the first visit to the office or clinic and the physician must see the practices established patients for any new medical problems.

To bill code 99211 appropriately, the nurse should document the date of the visit and a brief description of the reason for the visit, such as heparin or saline port flush, says Towle. In addition, the chart notes should identify the supervising physician. For example: April 5, patient came in for chemotherapy follow-up to ensure there are no toxic side effects and that the patient is responding to pain medication. Performed review of systems; no adverse effects found. Dr. Jones on-site.

These notations allow an auditor to know why the visit was necessary and that a physician was available in case a complication was discovered. That way, if an audit occurs, the auditor would know the physician was available to the nurse. In the absence of the declaration about the doctor being on-site, the physicians signature and date (and comments, as appropriate) also could validate the physicians supervision of the service, Towle says.

The guidelines for billing 99211 apply to all services that may not require the presence of a physician, which includes evaluations performed by physicians assistants (PA) and nurse practitioners (NP), who also may bill incident-to the doctors services.

Unlike registered nurses, PAs and NPs have their own billing numbers, and therefore use the same guidelines as a physician. PAs or NPs can bill either using their own billing numbers, or incident-to the doctors services, using the physicians billing number.

PAs and NPs are not limited to billing for any particular codes but can bill for whatever services they provide. They can bill either incident-to (if they meet all the rules) or under their own provider numbers if appropriate for the insurance carrier, Towle says. Nurses, on the other hand, are limited to 99211 services that may not require the presence of a physician.