Oncology Coding Alert-Expert Answers to Your Most Vexing Oncology Coding Questions
Oncology Coding Alert-Expert Answers to Your Most Vexing Oncology Coding Questions
Supervising Physician
Question: We are a freestanding clinic next to a hospital. Our medical oncologist is a contracted hospital physician. Can he bill Medicare for services provided in our office by our nurse if an emergency-room physician (who is not on the premises) acts as the supervising physician?
New York Subscriber
Answer: You must first determine whether your practice is hospital-based or a physician office. Some oncologists have offices in hospital buildings and either have their employees administer chemotherapy or use facility personnel and supplies.
If the physician uses hospital employees or facilities for chemotherapy services, he cannot bill. To consider chemotherapy as office-based, the oncologist must administer it:
1. In an office that is leased to the physician and not in a hospital outpatient department area
2. Using nurses employed by the physician
3. With the physician’s supplies and equipment.
Some non-Medicare payers and certain Medicare carriers might impose additional requirements. If the above are met, Medicare requires supervision of services, including administration of drugs and fluids provided by a nurse or other nonphysician. This is covered by Medicare as services "incident to" a physician’s, meaning a physician must be present in the office and immediately available to assist when services are furnished.
The supervising physician does not have to be the patient’s personal physician but can be another member of the group practice. In this case, the emergency-room physician, who is in a separate building, does not meet this requirement.
Supplies and Office Visits
Question: We have patients who come into our office to pick up a few weeks’ worth of supplies at a time. These include empty syringes, needles, dressings and Heparin. I was told supplies are considered part of the office visit, but because there is no visit, what is the best way to bill?
Answer: Medicare does not reimburse for the supplies listed because it includes them in patient care. Medicare will pay for supplies such as syringes and needles (A4206-A4209) when they are related to certain procedures like bone marrow biopsies (85102). However, this does not apply in the case you describe. Heparin (J1642) is a drug that Medicare carriers still pay for, but because the patient is taking it home, it is not reimbursable. If the patient’s insurance is a non-Medicare insurance plan, it is possible to bill for some of these supplies. You should check with your commercial payers to determine what will be covered.
If the quantity represents a lot of money, you should call the carrier to preauthorize the supplies. You should be prepared to explain why you want to send these home with the patient - for example, convenience or lack of pharmacy benefit that would require the patient to pay out of pocket. And, there is no office visit to code because one did not occur.
Dosimetry
Question: What is the "real" date of service for basic dosimetry calculations, 77300? Is it the day the patient is being simulated for radiation treatment, or is it the day the dosimetrist is calculating?
Indiana Subscriber
Answer: The dosimetrist does not require the presence of the patient to complete his professional services. Therefore, the date of service should be when the calculations are done. For example, if the patient was seen on Monday, and the calculation was performed the following day, 77300 (basic radiation dosimetry calculation, central axis depth dose, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, as required during course of treatment, only when prescribed by the treating physician) should be billed on Tuesday.
Calculation can be done on the date of simulation, but does not need to be. For example, the patient is simulated on Monday but the dosimetrist does not complete the calculations until Wednesday. Wednesday’s date should be used as the date for billing 77300, while the simulation, 77280-77295, would be billed on Monday.
Billing an Incomplete Test
Question: A patient comes in for a bone marrow test, but the doctor cannot reach the bone because the patient is obese. He reviews the laboratory test with the patient and proceeds with the test, but it is not completed. How should this be coded for Medicare?
Colorado Subscriber
Answer: If a bone marrow aspiration (85095) or biopsy (85102) was begun but not completed, i.e., the skin was incised or a needle was inserted, appending modifier -53 (discontinued procedure) might be appropriate. The CPT definition for modifier -53 states that "Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This may be reported by adding modifier-53 to the discontinued procedure code."
But appending modifier -53 might not be the deciding factor for reimbursement. The Medicare Carriers’ Manual in the Fee Schedule for Physicians’ Services, section 15900, addresses modifier -53 by stating, "... codes billed with this are subject to carrier medical review and priced by individual consideration."
In this instance, the proper coding for a bone marrow aspiration is 85095 with modifier -53. To withstand review of this claim, the patient record should include notes describing the procedure and when it was ended. A description of the patient’s obesity and the physician’s problem should also be included.
- Questions answered by Risë Marie Cleland, co-founder of Oplinc Oncology Services, a coding consulting firm in Lawton, Okla.; Laurie Lamar, RHIA, CCS, CTR, CCS-P, assistant director of reimbursement, public policy and practice department of the American Society of Clinical Oncology in Alexandria, Va. Her position does not reflect the opinion of ASCO; Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett, N.H.; and Margaret Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant and former director of the Tulane Cancer Center in New Orleans.
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