Part B Insider (Multispecialty) Coding Alert

Published on Sat Jan 14, 2006 PDF

Here are some important tips to capture demonstration reimbursement

Your oncology or hematology practice can receive an extra $23 for each evaluation and management visit you provide to patients with certain cancers this year.

That money is rightfully yours as long as you report one code each from G9050 to G9055, G9056 to G9062 and G9063 to G9130, says Sue Irwin with North Coast Electronic Billing in Elyria, OH. You should set up a charge sheet for your doctors that will let them use check marks to respond to the questions in the new 2006 cancer care demonstration project.

The Centers for Medicare & Medicaid Services has put out two Medlearn Matters articles about the new demonstration, SE0588 and SE0589. And the American Society for Clinical Oncology has put out a worksheet for each of the 13 cancer diagnoses covered by the demonstration project, notes Kimberly Branson, coding manager with Nashville Oncology Associates in Nashville, TN.

For example: With breast cancer, you're able to choose a code from among G9050-G9055 for the primary purpose of the visit, a code from G9056-G9062 for the disease state and a code from G9063-G9130 for the guidelines the physician used for treatment. Which code you use among G9063-G9130 depends on the type of cancer the patient has.

Important: Your physician must state the source of the guidelines he or she uses to treat the patient's cancer. You should actually write this in the comment line on the bill, and it should also be included in the patient's chart, says Branson. Guidelines could be from ASCO, the National Comprehensive Cancer Network, or both. Or you could mark "no guideline available," or "clinical trial," as applicable.

But if you use one of ASCO's worksheets, you can just have the physician circle the correct set of guidelines, Branson adds.  

In cases where the patient has already received chemotherapy and is in remission, it may take some effort for the physician to recall which treatment guidelines he or she used originally. Even if the purpose of the visit is just surveillance to look for disease recurrence for a patient with a history of cancer, the doctor still has to list the original treatment guidelines.

Watch out: When you're listing the disease state for many of the cancers, it should be the state when the patient was first diagnosed, not the current state, Branson warns. For example, for lung cancer, the form asks for "extent of disease originally established," from T1 through T3, before the patient received any treatment.

Coding glitch: CMS apparently goofed, because two sets of codes (G9119 through G9120 and G9121 through G9123) are exactly the same, according to Irwin. The descriptors are identical, except that one set has a semicolon and the other has "or." She's asked CMS which set to use, and hasn't yet received a response.

The project "shouldn't be as difficult as it looked like it might be," says Rise Cleland with Oplinc Oncology in Lawton, OK. The only tricky part may be keeping track of when to bill for the demonstration project. Last year's project was tied to any chemotherapy service, but this year's project is tied to E/M visits.

She recommends setting up a process in which you keep track of cancer patients who are coming in and might qualify for the program. The day before one of those patients comes in, someone should put the appropriate template form into the patient's chart. Some software vendors have already set up programs to help you deal with the demonstration project, she notes.