My provider performed a laparoscopic radical nephrectomy (90-day overall procedure) on a patient with a renal mass of concern for kidney cancer. I was told not to use a diagnosis of “kidney cancer” until cancer was proven, so I used an ICD-10 code of “kidney mass”. The final pathology report confirmed kidney cancer. My provider wants to bill post-op visits within 90 days saying billable because the patient now has a diagnosis of cancer that he didn’t have before the surgery. Can we charge for these visits?
The short answer is no. But it may be better to explain why Let’s start with the diagnostic code part. the International Classification of Diseases, Tenth Revision, Clinical Modification (CIM-10CM) instruct the clinician to choose a diagnosis code that accurately describes a patient’s clinical condition or reason for the visit. Additionally, the guidelines instruct the coder assisting the clinician to verify the appropriate code selection with the clinician when there is a question. In short, the clinician has the final say on the CIM-10-CM code must be used.
It is likely that some clinicians will say that, based on imaging alone, they are comfortable making a diagnosis of cancer without biopsy or tissue diagnosis, especially with the more modern imaging. However, we believe it remains best practice to use a cancer diagnosis code only in patients with pathologic tissue confirmation, with rare exceptions (such as cancer recurrence or metastases and those who need treatment and cannot get tissue). In addition to the medical implications of a cancer diagnosis, many of these diagnoses will affect the patient’s insurability and potential employment. From a coding perspective, diagnoses assigned prior to confirmation may result in the bundling of care that should be payable separately. That being said, a clinician must sometimes use their best clinical judgment when caring for an individual patient, as some patients may not be eligible for certain therapies without the corresponding diagnostic codes being chosen. However, in the case of the kidney mass mentioned above, most providers will use a “kidney mass” diagnosis code instead of a “kidney cancer” code.
Now let’s turn to the question of whether visits within 90 days of laparoscopic radical nephrectomy are billable if a patient now has a definite diagnosis of kidney cancer. The overall surgical package is set so that payment has already been made to include all necessary services normally provided by a surgeon before, during and after a procedure. This means that all hospital and outpatient visits that take place during this global period have been paid, with some exceptions. According to Medicare, services such as Assessment and Management (E/M) visits that are not included in the overall payment package and are payable separately within an overall period include:
1. Visits unrelated to the diagnosis for which the surgery is being performed, unless the visits are due to complications of surgery.
2. Treatment of the underlying condition or additional treatment that is not part of normal recovery after surgery.
In this particular case, the intent of the surgery was the treatment of known or suspected kidney cancer, whether or not a kidney cancer diagnosis code was used or was confirmed prior to the procedure. If the doctor had not suspected that the patient had cancer, the patient probably would not have had the nephrectomy. A computer may require and allow an E/M code to be reported with a different diagnosis than that used for surgery and the -24 modifier (Unrelated Service Assessment and Management by the same physician during a postoperative period), which states that the “physician may need to indicate that an assessment and management service was performed during a postoperative period for a reason or reasons unrelated to the initial procedure. However, the modifier definition is not diagnostic code specific, but rather focuses on “reason(s) unrelated to the original procedure”, and the Medicare rule is not limited to a specific diagnosis – “visits unrelated to the diagnosis for which the original surgical procedure is performed.”
Therefore, billing visits based solely on a diagnosis code change is not appropriate, as discussed in point 1 above. Visits are clearly linked to the reason(s) for which the surgical service was performed, regardless of the CIM-10-CM reported code for surgery department. On the other hand, the second point above deserves additional consideration.
Chemotherapy care provided for systemic cancer treatment is not related to recovery after surgery. Instead, it is targeted at treating the underlying disease and is an additional treatment that is not considered part of normal recovery after surgery. Under this exception, services related to the treatment of kidney cancer are chargeable.
Planning and follow-up visits over the overall period are not as clear. When reviewing multiple charts, it is common for a physician to discuss with the patient, prior to laparoscopic radical nephrectomy, the potential for kidney cancer and the need for further treatment after surgery, including chemotherapy . As this discussion is common for surgery, it is more difficult to support the position that this planning is not an integral part of recovery from surgery. If there is no suspicion of cancer and laparoscopic partial nephrectomy is performed with a finding of cancer during or after surgery, the argument that cancer treatment planning and cancer follow-up do not part of normal recovery is supported. Even with this differentiation, we must remember that relative value units and rules are developed not for the individual case but rather for the average case.
In summary, billing for visits during the postoperative period for cancer planning and follow-up will depend on the payer’s documentation and treatment. In general, similar to the discussion of stone prevention during the postoperative period of extracorporeal shock wave lithotripsy, payment may be warranted in some cases, but may be difficult to obtain.
Send coding and refund questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology time®, to [email protected]
Questions of general interest will be selected for publication. The information in this column is designed to be authoritative and every effort has been made to ensure its accuracy at the time of writing. However, readers are encouraged to check with their individual operator or private payers for updates and confirm that this information complies with their specific rules.