AMA Rejects Request For New Hem/Onc CPT Codes

Neltner Billing and Consulting recently submitted documents to the AMA suggesting that the infusion coding oncology and hematology rely on for appropriate payment of professional physician work and practice expense is failing in its purpose. Along with those documents we made requests for revised CPT coding to better reflect the work physicians are truly performing.

Unfortunately, the CPT Panel rejected our requests for the following reasons – with which we disagree:
1) They feel the existing E/M codes adequately describe physician services.
2) They feel our proposal lacked specialty society support.

1) We disagree and maintain that the existing E/M codes do not represent the professional work value associated with oncology/hematology treatment planning. They do not include specific bullet points or measures which can be scored to attribute to the level of service indicated. We have evidence that auditors continually fail to recognize the physician work associated with oncology/hematology planning in that levels of service are down-coded because credit is not properly attributed to the medical decision making. Auditors use medical necessity as the overarching criteria for down-coding the level of service, relying on the incorrect premise that a new problem, diagnosis or complication must be present in order to bill a level five service.

Auditors fail to recognize that a comprehensive review and exam combined with the high medical decision-making elements associated with administering drugs that cause extensive toxicity qualify as a level five service – even in a stable, chronically ill patient. The misunderstanding associated with what truly constitutes a level five service provides additional evidence that there is a need for separately reportable codes to identify the treatment planning elements of oncology and hematology encounters. The AMA coding in the infusion coding preamble discusses the highly complex nature of oncology care. Therefore, one code cannot come close to offering evidence of the different levels of care required to identify the correct treatment planning code for different levels of care.

2) With respect to a lack of support from specialty societies, we did receive and review the comments provided by the American Society of Clinical Oncology and the American Society of Hematology. While these societies ultimately don’t support the specific code requests, both expressed agreement with our contention that the physician work is not adequately captured with the existing E/M codes, nor is it included in the drug infusion codes. (Both societies indicated that a single code to represent oncology treatment planning would be more favorable rather than the proposed tiered set of codes.) With due respect, we do not believe that either ASCO or ASH understand what is happening in the community. After all if 95% of their members are under-coding – and hence, devaluing their service – who is going to complain? What we are experiencing is that auditors are looking at level five notes and calling them level three services.

Physicians across the US continue to down-code for fear of audits, and the work to defend their choice of high complex coding is under attack by carriers who use tactics of three formal reviews that will result in a lot work to defend an additional $40 payment per code. Also, these auditors and their processes do not allow a change in policy if you do actually win at the highest appeal. We have specific documentation to support this concern.

That is why we believe new coding with better definitions will resolve the concern.

Where do we go from here?
What we have done is ask the AMA to synchronize our coding request with the coding request proposed in 2004 by the Drug Administration work group (as suggested by ASCO and ASH). We would be pleased to have the Panel consider the proposed codes in a condensed format, represented by some variation of codes, rather than the series of codes originally requested. This would also be more consistent with the perspectives of ASCO and ASH.

We are hoping to hear back from the AMA and request reconsideration for this coding effort to be placed on the February 2010 agenda of the CPT Panel Executive Committee.

Stay tuned.