Evaluation and Management Coding. Disclaimer All CPT codes trademarked by the American Medical Association. All rights reserved. CARRIERS may differ

Evaluation and Management Coding

Disclaimer All CPT codes trademarked by the American Medical

Association. All rights reserved. CARRIERS may differ on E&M auditing criteria. This

workshop my not be exactly what your Medicare Administrative requires. This should not be the only source used for coding and

billing. All coding and billing decisions should be made on a case-by-case basis based upon documentation and insurance guidelines. All information contained herein is valid for the date of this seminar only. This presentation is based on national

guidelines. This presentation is a summary only. For Medicare

regulations, see www.cms.hhs.gov or your local Medicare web site.

Agenda

Introduction CMS Documentation Guidelines Major Components

History Physical Medical Decision-making

Common Oncology Services Best Practices and Practical Tips

Introduction

Evaluation and Management coding was introduced by the American Medical Association and CMS in 1993.

Ever since, providers have been confused about how to best document and bill for these services.

Oncologists are no exception to this rule. They tend to be overly-aggressive when billing initial services (consults and hospital admits) and not aggressive enough when billing office visits (99212-99215)---but every office is different.

Other Common Problems in Oncology

Poor chart legibility in terms of written notes, nursing documentation, and form completion.

Lack of understanding of E/M documentation criteria--particularly for counseling.

Consultations---these are a problem for every specialty--particularly the Medicare criteria.

Use of forms that are not inclusive all required data elements.

Electronic templates that are the same for everyone, regardless of condition.

Mismatch of billed DOS and actual DOS in hospital charts.

Thinking that just because Oncology patients are “sicker” that higher level services are billable for every patient.

Documentation Guidelines

“If it wasn’t written, it wasn’t done: This also includes:

“If you can’t read it, it wasn’t done” “If you can’t find it, it wasn’t done” “If it is not filed in the record, it wasn’t

done.” “If it was not ordered, it wasn’t

necessary.”

Documentation Guidelines

General Principles (CMS) for your charts-- The medical record must be complete and

legible. The documentation of the each patient

encounter must include Reason for the encounter and relevant history,

physical, and prior health examination results; Assessment, clinical impression, or diagnosis; Plan for care; and, Date and legible identity of the observer.

CMS Documentation Guidelines (cont’d)

If it is not documented, the rationale for ordering diagnostic and other ancillary services should easily be inferred.

Past and present diagnoses should be accessible to the treating and/or consulting physician.

Appropriate health risk factors should be identified.

The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented.

AND, the CPT and ICD-9-CM codes reported on the bill should be supported by the documentation in the medical record.

Do your records meet these standards?

Review Question

The documentation for each encounter must include:

a) Reason for the encounter and relevant history, physical, and prior health examination results

b) Assessment, clinical impression, or diagnosisc) Plan for cared) Date and legible identity of the observer.e) None of the abovef) All of the above

Review Question

If a physician discovers a side effect during the physical examination and decides to treat it with a billable item or service, they need to make sure that they document the new diagnosis in the record and notify their billing staff.

a) Trueb) False

Evaluation and Management Services

Documentation Guidelines History Physical Medical Decision-making

Categories of E/M Services

• Office/Other Outpatient

• Hospital Inpatient• Consultations• Hospital Observation• Emergency

Department• Prolonged Services

• Nursing Facility• Domiciliary, Rest

Home or Custodial Care

• Home• Case Management• Preventive Medicine• Special Services

Each E/M service category has special instructions for use

AMA 2004 CPT Manual

E/M Definition of a New Patient

A new patient is one that has not been seen by the documenting physician or a member of their specialty in the same group practice in the past three years (thirty-six months). This does not mean that a second consult

would not be allowed, if it was medically necessary and met consultation criteria.

It does mean that, if you hire a physician from across town, their patients would NOT be new patients.

Type of Common E/M Services

Initial Encounter

CPT Codes 99201-9920599221-99223

Subsequent EncounterCPT Codes99212-99215 99231-99233

Discharge EncounterCPT Codes 99238-99239

Consultation

CPT Codes99241-99255

An initial inpatient encounter may be billed by admitting physician onlyA new patient visit will be billed if the patient is referred for a known care plan and it meets the definition of new patient.

Only one visit per day per member of the same specialty in the same group.

For concurrent care, make sure your specialty diagnosis is on the claim.

Utilized by physician to report all services provided on date of discharge, service need not be continuous

Requires a request Requires a reason Rendering an opinion/advice Respond to requesting physician in writing Transfer of care???

Requires 3 of 3 key components: history, exam and decision making


Requires time documented if 30 minutes or more as well as services provided for over 30 minutes.


1995 Versus 1997 Criteria for E&M

Only difference is the physical exam In 1997, single organ exams are outlined that do

not really apply to Oncologists, e.g. musculoskeletal, urologic.

1997 multi-system exam is much more detailed and is harder to get to a higher code, unless documentation is detailed.

1997 does give credit for partial exams of body areas or organ systems, which 1995 does not.

1995 is used most frequently by Oncologists. But, Medicare will use either that is most favorable in an audit. Just be consistent for every visit.

See these at http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asphttp://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp

Driving Force of E/M Medical Necessity

“ NPP (the nature of the presenting problem)…is the indicator for selecting the appropriate level of medical care warranted by the severity of the patient’s illness.”THE NATURE OF THE PRESENTING PROBLEM INDICATES THE LEVEL OF MEDICAL CARE AND CODING WARRANTED BY THE PATIENT’S ILLNESS. IT IS THE CPT CODING SYSTEM’S E/M VEHICLE FOR EVALUATING MEDICAL NECESSITY.

Practical E/MStephen R. Levinson, MD

Nature of the Presenting Problem

Example: subsequent hospital visits 99231--Usually the patient is stable, recovering,

or improving 99232--Usually the patient is responding

inadequately to therapy or has developed a minor complication.

99233--Usually the patient is unstable or has developed a significant complication or new problem.

If you find out in the history the patient is stable, recovering, and/or improving--how much do you really need to do in terms of physical and decision-making?

Medical Necessity (Trailblazer)

1. The guiding principle of Medicare is whether an item or service was “medically necessary”. For E&M, this means

Frequency of service/ intensity of service. Separate from whether criteria was met. Does the H&P meet the patient’s actual

needs at the time of service? If so, you can prove to an auditor that the encounter met medical necessity criteria. Someday, this may be more important than you think right now.

Medical Necessity (Trailblazer)

2. Information used by Medicare is contained within the medical record documentation of the history, physical, and medical decision-making. Medical necessity is based on these attributes:

Number, acuity, and severity of problems addressed in the E&M criteria.

Context of the service in terms of other services previously rendered for the same problem.

Complexity of documented co-morbidities that influence physician work.

Physical scope encompassed by the problems, i.e. number of physical systems affected by the problem.

Medical Necessity Tips (Trailblazer)

Identify presenting complaints and/or reasons for the visit. Demonstrate the history, physical and MDM

associated with each. Demonstrate how physician work was affected by

co-morbidities or chronic problems noted. Ensure that the nature of the presenting problem is

consistent with the level billed (99213 = low to moderate severity).

Become familiar with the clinical examples in CPT Appendix C of the book.

Review question

Why is nature of the presenting problem important?

a) You get paid more for it.b) It reflects the patient’s complaintc) It shows you know your

documentation guidelinesd) It drives the level of history, physical,

and medical decision-making of the encounter

e) None of the above

Components of E&M Services

Major Components History Physical Medical Decision-making

Number of these that must be included by type of visit: All three for consults, initial admissions, and

new patients 2 of 3 for established or follow up encounters.

Components of E&M Services

Other Components that are important but are not key components Counseling Coordination of Care Nature of Presenting Problem Time

The History: Its Components

Chief Complaint History of Present Illness (HPI) Review of Systems (ROS) Past, Family, and Social History

History

Chief Complaint--A brief statement,generally in the patient’s own words or by the physician, conveying the reason for the visit to the physician/provider. This can be documented by the patient, the nurse, or the provider.

Chief Complaint

The medical record should clearly reflect the chief complaint for every encounter.

The chief complaint should be the reason that instigated today’s encounter.

This can include symptom, problem, condition, diagnosis, ‘return to’ ordered by physician, or other factor that is the reason for the encounter.

Don’t say that patient came in for “follow up” with no problem for which they need follow up.

History of Present Illness (HPI)

HPI is a chronological narrative of the course of the patient’s presenting illness, from its initial date of diagnosis to the present visit. This should also include any complicating factors or co-morbidities. The HPI includes assessment and documentation of one to eight elements…

History of Present Illness (HPI)

Elements include: Location Quality Severity Duration Timing Context Modifying Factors Associated Signs and Symptoms

Dimensions of the HPI

Location Site of problem

Duration Length of time existed

Timing Regularity of occurrences

Severity Intensity or degree

Quality Description or characteristic

Context Events surrounding occurrence

Modify Factor Effect on symptom

Associated Signs & Symptoms

Significantly related to presenting problem

AMA 2008 CPT Manual

History of Present illness

Documentation of HPI BRIEF:1-3 elements of the HPI. EXTENDED: 4 or more elements of the

HPI. The specificity of the HPI can also

describe the medical necessity of why the patient is being seen and the level of service that may be billed.

Documentation Example of HPI

45 year old female lung cancer patient complains of intermittent sharp pain in her left hip after falling out of bed today. Additionally, she complains of left leg numbness; describing the pain as a 9 on a scale of 1-10. She states aspirin has not relieved this pain.

Evaluation of Example HPI

45 year old female lung cancer patient complains of intermittent sharp pain in her left hip after from bed . Additionally, she complains of left leg numbness; describing the pain as a 9 on a scale of 1-10. She states aspirin has not relieved this pain.

Location = Hip Duration = today Timing = intermittent Severity = 9 (scale 1-10) Quality = sharp pain Context = falling from

bed, lung cancer Modifying Factor = aspirin Associated S&S = pain,

numbness in leg

Review of Systems: Next Component of the History

Documents the patient’s responses to a series of questions of their experiences, symptoms, or irregularities in fourteen medical systems. This can be current (since the last visit) or chronic but still a factor in today’s treatment or problem.

Review of Systems

Systems to be documented Constitutional Eyes Ear, Nose, Throat, Mouth Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (includes breasts) Neurological Psychiatric Endocrine Hematological/lymphatic Allergic/immunologic

Review of Systems (ROS)

A problem pertinent ROS identified, through a series of questions, inquires about the system directly related to the problem

Extended ROS must identify the positive responses and pertinent negatives for at least (2) and not more than (9) systems

Complete ROS must evidence documentation of ten organ systems. The attending physician may use “All other systems negative” when (2) pertinent positives and/or negatives are documented. In absence of such a notation, all systems must be documented. Some Medicare contractors do not allow this notation at all anymore--always check your contractor’s web site.

If unable to obtain, document why, If the patient is unable to communicate due to mental state or language barrier “ROS unavailable due to …..” unconscious, intubated, poor historian, non-English speaking without a translator.

Review of Systems

Tips for ROS Can be documented by someone else-- NP, RN,

the patient on a form or from another MD’s history—but, the documenting provider should initial and date or refer to it in dictation. Obviously, the patient needs to respond to these, if you use their responses.

If available in the chart, can use former ones if referred to by date of review of systems--but it must be relevant to today’s service.

Noted presenting problems may be included in the ROS, even if they are also in the History of Present Illness.

Past, Family, Social History

What are they? PAST: Patient’s past experience with illnesses,

operations, injuries,medications (prescriptions, herbal, OTC), allergies, and treatments.

FAMILY: Medical events in the patient’s family that pose a risk to the patient and/or are related to the current illness or chief complaint.

SOCIAL: An age appropriate review of past and current activity which can include marital status, employment history, sexual history, living arrangements, smoking (primary and secondary), drinking, or exposure to environmental toxins.

Past, Family, Social History

Levels: Pertinent = At least one from any of these areas Complete:

For established patients in the office at least two of these. For new patients and hospital patients, plus initial visits

anywhere all three are necessary Can refer to a prior assessment and state that it is

unchanged. Again, this is questionable if it appears in every single visit.

Do not state that PFSH is ‘non-contributory’. State the actual status of question asked. “Negative” is an acceptable response, if it is specific to the area reviewed.

This may documented by the patient, a staff member, or the physician. The physician (or other billing provider) must refer to it or sign and date documentation by others.

E/M Levels in Review: The History

History Focused Expanded Detailed Comprehensive

CC Required Required Required Required

HPI 1-3 Elements

1-3 Elements

4+ Elements

4+ Elements

ROS N/A 1 System

2-9 Systems

10+ Systems

PFSH N/A N/A 1 Element

3 of 3 Elements(new/consult)

2 of 3 (est)

Review Question

To bill for a high level consult , how many HPI elements do you need?

a) 2 are listed and the rest are non-contributory.b) 10c) 4d) 8-12e) None of the above

Review Question

You need to document a past, family and social history every time the patient comes in?

a) True b) False

Examination (1995)

Body Areas: Head including face Neck Chest including breasts and axillae Abdomen Back Genitalia, groin, and buttocks Each extremity

Examination

Organ Systems Constitutional Eyes Ear, Nose, Throat, Mouth Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (includes breasts) Neurological Psychiatric Endocrine Hematological/lymphatic Allergic/immunologic

Examination (1995)

Levels: Problem Focused = a limited exam of affected

body area or organ system. Expanded Problem Focused = a limited exam

of affected areas and other symptomatic or related organ systems (2-7 organ systems).

Detailed = an extended examination of affected areas and other symptomatic or related organs (2-7 organ systems).

Comprehensive = a general multi-system examination or a complete examination of a single organ system. Generally, this is 8-12 organ systems for a multi-system exam.

The Examination (1995) Tips the Exam:

It is preferable that a provider (MDs or NPPs) performs the exam as necessary to ascertain abnormalities. But, Nurses and MAs can do constitutional part.

The type of exam must be relevant to the diagnosis and the severity of the problem. Doing a comprehensive exam or having a template that does it can be a problem unless the patient actually needs the exam. Always examine systems most relevant to the presenting problem.

The depth of the exam description can drive whether it is DETAILED OR EPF, both are 2-7 organ systems. ENTM must include the ears, nose, throat, and mouth. Lymph nodes must be include all nodes for the system to be ‘detailed’..

Brief statement or notation indicating “negative” or “normal” is sufficient for findings within normal limits

Documentation of “abnormal” is not sufficient without elaboration.

Review Question

To document a detailed exam (say, for a 99214) under 1995 criteria, you need what..?

a) 2-7 body areasb) 2 complete organ systemsc) 2-7 organ systems in detaild) One complete exam of the area most

relevant to the chief complaint.e) None of the above

Review Question

You can use body area exams as a basis for lower level visits.

a) Trueb) False

Medical Decision-Making

What is this? Two out of three of these-- The number of possible diagnoses and

treatment options that must be considered in light of the presenting problem and HPI.

The amount or complexity of data considered, i.e. diagnostic tests, medical records, and/or other information obtained including from additional providers.

The risk of significant complications, morbidity, or mortality associated with the patient’s presenting problems, diagnostic procedures ordered, and/or possible or definite treatment options.

Medical Decision-Making

Number of Diagnoses and Treatment Options Diagnosis (es) treated today are those counted. Patients with co-morbidities that impact current

treatment are more complex. These should be discussed.

For established diagnoses, it should be shown if they are worsening, improved, controlled or complicating.

The necessity to change the course of treatment must be documented. If the treatment is unchanged, this is a lower level of decision-making.

Referrals and consultations are a treatment option.

Number of Diagnoses/Treatment Options

This is again what diagnoses you considered in making a decision for today’s encounter. Just because a patient has lots of diagnoses does not always put you at a higher level, if they are not addressed in the specific encounter.

Improved, feeling well, or stable lower the intensity of the diagnosis criteria.

Consultations, review of information with other physicians to arrive at a treatment or diagnosis is considered higher level.

Amount or Complexity of Data Reviewed

Types of testing done and reviewed dictates severity, i.e. a cardiac cath as opposed to a CBC.

Independent review of specimens and smears is more complex.

Review of old records or obtaining a history from someone other than the patient is a higher level, if new information is obtained.

Discussions of tests with the performing physician is considered more complex.

Medical Decision Making Data Complexity Elements: Example of ScoringAmount and/or Complexity of data reviewedPoints are assigned to each section below based on the number of data items reviewed max = 4 pts

Points

Total

Review and/or order of clinical labs 1 1

Review and/or order of tests Radiologic study, other non invasive diagnostic study

1

Discussion of diagnostic study w/interpreting MD 1

Decision to obtain old records and/or obtaining history from someone other than the patient

1

Review and summarization of old records or gathering data from source other than patient

2

Independent visualization of image, tracing or specimen itself

2 2

Total Points 3

E/M – Medical Decision Making Component

Risk of Complication and/or Morbidity/Mortality

Four Levels Minimal Low Moderate High

Risk of Complications, Morbidity and/or Mortality

Refers to patient’s level of risk at the visit

Sources of risk Presenting problem Diagnostic procedures ordered Management options selected

Illustrated by clinical examples in “Table of Risk”

1995 Documentation Guidelines

Level of Risk

Presenting Problem(s) Diagnostic Procedure(s) Ordered

Management Option Selected

Minimal

* One self–limited or minor problem,

e.g. cold, insect bite

*Lab tests requiring venipuncture*CXRs*ECG/EEG, U/A, echo

* Rest* Gargles* Elastic bandages* Superficial dressings

Low •2 or more self–limited or minor problems•1 stable chronic illnessAcute uncomplicated illness or injury, e.g. cystitis, sprain

* Physiologic tests not under stress, e.g. PFTs* Non–CV imaging with contrast, e.g. barium enema* Superficial needle biopsy* Clinical lab test requiring arterial puncture* Skin biopsies

* OTC drugs* Minor surgery w/ no identified risk factors* PT, OT•IV fluids w/out additives

Moderate

* 1 or more chronic illnesses with mild exacerbation, progression, or side effects of treatment* 2 or more stable chronic illnesses* Undiagnosed new problem with uncertain prognosis, e.g., lump in breast* Acute illness with systemic symptoms, e.g. pyelonephritis, pneumonia, colitis* Acute complicated injury, e.g. head injury with brief LOC

* Physiologic test under stress, e.g. cardiac stress test, fetal contraction stress test* Diagnostic endoscopies with no identified risk factors* Deep needle or incisional biopsy* CV imaging studies with contrast and no identified risk factors, e.g. arteriogram and cardiac cath* Obtain fluid from body cavity

* Minor surgery with identified risk factors* Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors* Prescription drugs* Therapeutic nuclear medicine* IV fluids w/ additives* Closed tx of fracture or dislocation without manipulation

High * 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment* Acute or chronic illnesses or injuries that may pose a threat to life or bodily functions, e.g. peritonitis, acute failure, multiple injuries, acute MI* An abrupt change in neurological status, e.g. seizure

* CV imaging studies with contrast with identified risk factors* Cardiac EP test* Diagnostic endoscopies with identified risk factors* Discography

*Elective major surgery w/ identified risk factors* Emergency major surgery* Parenteral controlled substances* Drug therapy requiring intensive monitoring for toxicity* Decision not to resuscitate or to de–escalate care because of poor prognosis

Table of Risk (USE THE HIGHEST LEVEL DOCUMENTED) Table of Risk (USE THE HIGHEST LEVEL DOCUMENTED)

Documentation Tips for MDM

Established diagnoses should indicate: Stable, well-controlled, worsening, failing to improve

Independent review of diagnostic test should document: visualization of image, tracing or specimen

Review of old records, document findings or lack of findings

Document co-morbidities, underlying diseases that increase risk of treating that patient.

Medical Decision Making (MDM)

Four levels: Straightforward Low complexity Moderate

complexity complexity

High

Two of the three areas:Two of the three areas:

Dx. Options, Amount of Data, and Dx. Options, Amount of Data, and Risk Establish the MDM LevelRisk Establish the MDM Level

Dx./mgt. options

0-1 2 3 4

Amount of data

0-1 2 3 4

Overall risk Minimal Low Moderate High

Level of MDM Straightforward

9924199242

Low992219923199243

Moderate992229923299244

High992239923399245

Review Question

All cancer patients have severe diagnoses and significant risk of death or morbidity; therefore, we always have high-level decision-making.

a) Trueb) False

Counseling/Coordination of Care

When counseling dominates >50% of the visit, time may be used as the dominating factor---BUT READ THE FINE PRINT!

Counseling/Coordination of Care

Must document the following three items: Total Visit Time

99214 = 25 minutes 99215 = 40 minutes

Time Spent Counseling (must be over 50%) Subject Matter of Counseling—diagnosis,

prognosis, code status, side effects, chemo options, etc.

This is incorrectly documented or under-billed in Medical Oncology.

Counseling/ Coordination of Care

Counseling is a discussion with the patient and/or family (Medicare patients must ALWAYS be present) concerning one or more of the following areas: Diagnostic results, impressions, and /or

recommended diagnostic studies; Prognosis, risks and benefits of management

(treatment) options; instructions for management and/or follow-up; importance of compliance with chosen management options;

Risk factor reduction; and patient family education

Review Question

Ms. Genesis, a Medicare patient, is in the hospital with terminal cancer. Her family comes to the office for a 40-minutes discussion about her prognosis. What can you bill?

a) 99213b) 99214c) 99215d) Not enough informatione) None of the above

Putting it All Together: Office VisitsKey Factors 2 of 3

Level 5 Level 4 Level 3

History• HPI• ROS• PFSH

• 4• 10• 2 of 3

• 4• 2• 1 of 3

• 1• 1• NA

EXAM 8 organ systems a) An extended exam of affected area 2-7 organ systems or b) 12 bullets (1997)

a) Limited exam of affected and related system (2-7) or b) 6 bullets (1997)

MDM (2 of 3)• Dx/Tx Options• Data• Risk

High Complexity• Extensive• Extensive• High

Moderate• Multiple• Moderate• Moderate

Low Complexity• Limited• Limited• Low

Bell Curve 2005: Hem-Onc

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

1 2 3 4 5Level of Office Visit (83)

% of Medicare SVCS Est OV 2005

% of SVCS

Putting it All Together-- Consults

Key Factors 3 of 3

Level 5 Level 4 Level 3

History• HPI• ROS• PFSH

• 4• 10• All Three

• 4• 10• All Three

• 4• 2• 1 of 3

EXAM 8 organ systems 8 organ systems a) An extended exam of affected area or b) 12 bullets (1997)

MDM (2 of 3)• Dx/Tx Options• Data• Risk

High Complexity• Extensive• Extensive• High

Moderate• Multiple• Moderate• Moderate

Low Complexity• Limited• Limited• Low

Bell Curve 2005: Hem-Onc

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

1 2 3 4 5Levels of Service

Medicare Office Consults 2005 (83)

Series1

Review Question

You are auditing your partner, Dr. James, who has billed all of her visits this year to 99214. Her EMR documentation seems to be perfect. Is there a problem here?

a) No, all you need is good documentation.b) Yes, you set up red flags when you repeatedly

bill to one level.c) No, our EMR takes care of good documentation.d) Yes, all of the 99214s could not be medically

necessary and, by the way, shouldn’t there be some 99215s?

Common Oncology Services

Medicare Consultations (Medicare)

Transmittal 788, CR #4215, December 2005 No shared visits for consultations in either office or hospital.

Either the NPP or MD should charge for the consult. This is black and white in the transmittal.

3 R’s have been more formalized and one has been added… REQUEST from another physician for consultant’s

opinion must be clearly documented in BOTH the receiving and referring physician charts.

Referring MDs must have it in their plan of care, but there is no need for you to check every record.

The REASON for the consult must be clearly documented in the medical record.

Opinion RENDERED by the consultant with RECOMMENDATIONS for treatment.

REPORT goes back to the referring physician. 99211 may not be used for a consult.

Consultations

Consultations (Cont’d) Consultations may be billed based on

time for counseling/coordination of care, but an opinion must be rendered.

Also, if care is continuous before the consult for the same/original problem, an additional consult may not be billed.

Only ONE consultation may be billed per inpatient stay.

Consultations

Transfer of Care A transfer of care occurs when a physician or NPP requests that

another physician or NPP take over the responsibility for managing the patient’s complete care for the condition, and does not expect to continue treating or caring for the patient for that condition.

When this transfer is arranged, the requesting provider is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for the condition. The receiving physician or NPP shall document this transfer of the patient’s care in the patient’s medical record or plan of care.

If a transfer of care occurs, report the appropriate new or established patient visit code should be billed based on place of service.

51 Specialty Societies have objected to this language (including the AMA, ASCO, and ASH), but this Transmittal is still in effect and has been the Medicare rule since 1/1/2006.

Other Common E/M Services in Med Oncology

Hospital Admissions (99221-99223) Patient must be admitted by you for

this to be billed by you This may be the only service billed in a

day, so add all documentation for that day into your level of service.

Billed for admission that lasts over one calendar day.

Other Common Services in Medical Oncology

Hospital Follow Up Visits (99231-99233) Dominating factor is nature of the

presenting problem. May use as a hospital discharge service

if you are not discharging the patient. May only be billed once per day by a

member of your specialty in your practice.

Prolonged Services (99354-99357)

These should be billed with other codes for extra time spent cumulatively face-to-face with the patient. 99354-99355 go with office/outpatient services 99356-99357 go with hospital inpatient services

Document your time and it must be based on 30 minutes past the CPT time. Services of less than thirty minutes past the visit time are not chargeable. 99214 (25 minutes in CPT book) can only be charged

with 99354, if the visit is longer than 55 minutes. Counseling must be over 70 minutes as you must bill

99215 with prolonged services of counseling.

Modifier -25

Modifier -25 must be used on E/M services on the same day as drug administration services.

Per Claims Processing Manual Chapter 12, Section 30.6.7 (D) Medicare will pay for medically necessary

office/outpatient visits billed the same day as a drug administration service with Modifier -25 when the modifier indicates that a significant, medically necessary, separately identifiable Evaluation & Management service was performed and documented that meets a higher complexity level of care than a service than 99211. No separate diagnosis is necessary.

Review Question

Dr. Hayes, a surgeon, sends Ms. Jones, a Stage II breast cancer to your practice. She has had her surgery and Radiation and now she is ready for chemotherapy. Dr. Hayes says in his note: “Please see patient for chemotherapy administration”. Is this a consultation?

a) Yesb) No

Review Question

Your patient, Mr. Ramsey, has COPD and lung cancer. The pulmonologist admitted the patient to the hospital and you are following the patient there. Can you get paid if you both submit a bill for a hospital visit?

a) No, it is concurrent careb) Yes, if you use the lung cancer diagnosis and

it was the reason you are following Mr. Ramsey

c) Not enough informationd) I never bill for these visits.

Practical Tips and Best Practices

o Know the criteria for every E/M service you perform. To best accomplish this, read the E/M Documentation Guidelines once per year.

o Do not use templates for EMRs or dictation, unless you are 100% positive that they meet E/M criteria. Use only one format per practice.

o Do not stand for illegibility on the part of any provider in your group.


Think about medical necessity when billing for E/M services. Just because you can fill in the boxes on a form or EMR does not mean that the patient needs that level of care.

“Clustering” at any one level of service may target you for an insurance audit.


Getting a patient history every time the patient comes into the practice is only relevant insofar as to changes in condition or chronic conditions that are important in current treatment.

Be sure you know the difference between a consultation and a new patient referral. Not EVERY INITIAL visit is a consult.

Have a peer review process in your practice for E/M services. You are liable for every provider billing under practice’s Tax identification number.

What can you do? Enlist support from these areas:

Nurse Practitioners and PAs (for more efficiency in your practice).

Patient Surveys (Read, Initial, Date) Lab Data (Read, Initial, Date) Past Reports (Refer back)

Blanks in dictation can be gaps in payment or liability issues.

Do not forget to document changes in diagnoses in the medical record.

Treat your medical records like your checkbook!