Payment for Cancer Treatment Depends on Documentation
Published on Wed Dec 01, 1999
Insurers often fail to acknowledge the unique complexity of cancer treatment and the level of E/M services needed. This often leads to the carriers downcoding the claims. Then, frustration with downcoding and concern about audit or fraud allegations eventually cause oncologists to begin undercoding visits rather than taking the time to make sure documentation supports a higher-level code that could be justified but ultimately gets reduced.
Gary Bien, the practice administrator at Hematology/Oncology of Indiana, says lack of proper documentation is the chief barrier standing in the way of deserved higher reimbursement.
Without proper documentation, the oncologists are vulnerable. The specificity with which the oncologist dictates information regarding a case is always going to be the best basis for determining whether claims will be paid, he observes.
What Is Enough Documentation?
But how can you tell if theres enough detail in the chart? For example, would a level 5 new patient office visit (99205) be supported by the following notations: Patient is a 29-year-old female newly diagnosed with Stage I invasive breast cancer, upper outer quadrant (174.4)? She elected to have a simple mastectomy (19180) and a sentinel node biopsy (38792), which showed no cancer cells. The tumor was 1.2 cm in diameter and estrogen receptor negative. Chemosensitivity testing showed the tumor to be resistant to methotrexate. The patient has been married for two years, and she and her husband (who accompanied her on the visit) want to have children and are concerned that chemotherapy may put her into premature menopause.
She is also worried about her risk of recurrence because her mother died of breast cancer at age 35. She has joined a support group and has been searching the Internet and thus has questions about complementary therapies, particularly acupuncture and Chinese herbs, and how those might affect her prognosis.
The CPT criteria for a new patient office visit (99205) include these three key components: a comprehensive history, a comprehensive examination and medical decision-making of high complexity. The presenting problem(s) are of moderate to high severity, and the physician typically spends 60 minutes face-to-face with the patient and/or family. Therefore, check the patients chart to ensure the oncologist noted face-to-face time spent with the patient. Considering the complexity of care, the visit certainly could have taken 60 minutes or more.
According to Doris Byrem, practice manager at Davis, Posteraro & Wasser, an oncology group practice in Manchester, CT, Physicians tend not to count time. They may come out from a visit of more than an hour and not mention the duration in their notes.
Tip: Prolonged visits (99354-99357) are not unusual in oncology, particularly with newly diagnosed patients.
This case requires a comprehensive history [...]
