Pending E/M Coding Changes & Radiation Oncology Billing

Posted by Robert Lynch on Oct 24, 2017 10:47:58 AM
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Among the many provisions detailed within the 2018 Physician Fee Schedule Proposed Rule, CMS acknowledges that the current evaluation and management documentation guidelines create an administrative burden and increased audit risk for providers.

“Stakeholders have long maintained that both the 1995 and 1997 guidelines are administratively burdensome and outdated with respect to the practice of medicine, stating that they are too complex, ambiguous, and that they fail to distinguish meaningful differences among code levels.”

In response, CMS announced its intention to revise the current E/M documentation guidelines. This revision will likely include removal of the history and exam documentation requirements:

“We are also specifically seeking comment on whether it would be appropriate to remove our documentation requirements for the history and physical exam for all E/M visits at all levels. We believe medical decision-making and time are the more significant factors in distinguishing visit levels….”

Although any proposed change will carry much more significance for specialties with larger portions of overall charges tied to E/M codes, we believe radiation oncology providers can begin making changes in documentation habits now to help prepare for pending changes.

Overall the key driver in radiation therapy revenue is the weekly treatment management code for the professional fee (up to 30% of all revenue) and the treatment delivery codes for the free-standing facility (up to 55% of all revenue) while the E/M codes tend to represent less than 10% of overall revenue for either.  However, it is important to optimize every aspect of your radiation oncology revenue cycle and E/M charges are meaningful.

As New Bedford reviews data from numerous clients, we have found that often the dependence on time as the key component will produce a higher level of E/M service without the burden of history and physical exam documentation required to support a higher level of E/M code.  If the radiation oncologist elects to report the level of service based on time spent in counseling and/or coordination of care, the total length of time of the encounter should be documented and the record should describe the counseling and/or activities to coordinate care.

When counseling and/or coordination of care dominates (more than 50 percent of) the
physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting), time is considered the key or controlling factor to qualify for a particular level of E/M services. If the level of service is reported based on counseling and/or coordination of care, you should document the total length of time of the encounter and the record should describe the counseling and/or activities to coordinate care. Each E/M code includes a reference time to guide when using time as the key component.  For example, a level 3 established patient outpatient visit (99213) has a reference time of 15 minutes, and a level 4 service (99214) has a reference time of 25 minutes.

Overall, CMS is driving the healthcare system to increased investment in comprehensive care management and coordination services.  In general, we believe capturing the time in face to face E/M visits will not only become more important in the future but possibly lead to better revenue in the near term as well.

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Topics: Radiation Oncology Coding

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