Coding Corner: Time Spent on Chemotherapy Initiation | Rebekah Summey, MD
CMS no longer requires 50% of time billed to be spent face-to-face or in coordination of care. Therefore, time spent on patient care, such as placing orders and documentation, can be included in the time spent on a visit, even if non-patient-facing activities take longer than the time spent with the patient. An additional consideration with chemotherapy-related counseling is to “break” the global postoperative period in order to bill chemotherapy-related services separately.
Scenario 1: Postoperative counseling prior to chemotherapy initiation
You perform a robotic-assisted TLH, BSO, sentinel lymph node dissection for a patient with stage IB serous endometrial cancer. At her 2-week postoperative visit, you counsel her on your recommendation for chemotherapy. You bill with diagnosis codes of C54.1 (malignant neoplasm of the endometrium), Z71.89 (other specified counseling) and add a modifier 24 (unrelated evaluation and management service by the same physician or qualified health care professional during a post-operative period) on to your E&M code. This “breaks” the global postoperative period. This allows you to bill for services (chemotherapy counseling) that are performed in addition to those related to surgery.
Scenario 2: Chemotherapy ordering on a separate day
You perform a robotic-assisted TLH, BSO, sentinel lymph node dissection for a different patient with stage IB serous endometrial cancer. You discuss her at tumor board and place her chemotherapy orders on the day of tumor board. You do not bill an E&M service on the same day. Since this work is done on a day when a visit is not performed, you cannot bill for the time spent ordering chemo.
Scenario 3: Chemotherapy change
You are treating a recurrent ovarian cancer patient with a platinum-based regimen. At her pre-chemotherapy appointment, her CT scan shows progressive disease. You elect to change treatment to doxorubicin, and counsel her regarding this plan. You place new orders for the change in treatment plan, and she is treated the next day. You bill with an ovarian cancer diagnosis code plus Z01.818 (encounter for examination prior to chemotherapy). If billing for time with your E&M code, you may include the total time spent on the visit, documentation, chemotherapy orders, and any other care coordination. For more details regarding pre-chemo visit coding, please see the most recent Q&A in the Coding section of the SGO website.
Rebekah Summey, MD, is a Gynecologic Oncology Fellow at the Medical College of Wisconsin in Milwaukee, WI.