Health Information Management

Create communication between clinical and coding staff for chemotherapy reporting

JustCoding News: Outpatient, February 8, 2012

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Chemotherapy infusions sit at the top of the CPT® hierarchy for coding injections and infusions. To code chemotherapy properly, coders need to understand what the clinical staff actually does for the patient via complete and accurate documentation.

This is not unique to chemotherapy coding, of course. Incomplete documentation is a perennial problem for just about every type of coding. But chemotherapy and other injections and infusions present some unique challenges in part because clinical staff members are focused more on patient care than documentation requirements, says Paula Lewis-Patterson, BSN, MSN, NEA-BC, clinical administrative director of the ambulatory treatment center at The University of Texas MD Anderson Cancer Center in Houston.

Lewis-Patterson and her staff treated more than 110,000 patients in 2011, making MD Anderson one of the largest outpatient chemotherapy infusion centers in the United States. Because of this high volume of patients and the associated high costs of treatment and revenue, Lewis-Patterson and others at MD Anderson had to find ways to for clinical and coding staff to work together to capture charges.

Focus on patient care
A nurse’s first priority is patient care, Lewis-Patterson says. The nurse must focus on ensuring the patient receives the correct chemotherapy and other medications more than documentation. “That's why we went to nursing school,” Lewis-Patterson says. “We would much rather take care of patients than submit charges.”

At MD Anderson, a nurse goes through 15 steps before hanging any chemotherapy, Lewis-Patterson says. Nurses focus on patient safety issues prior to administering chemotherapy, for example, dose recalculation, lab results, IV access, right patient, right route, right rate, right time, and allergies.  As a result, nurses don’t always document everything coders need.

For example, missing stop times are sometimes a problem at MD Anderson. “We’re great at start times. Stop times, not so much,” Lewis-Patterson says.

Although CMS does not specifically state that it “requires” documented start and stop times, it does say things like it has the expectation that hospitals will document time, otherwise CMS has a difficult time understanding how services would be billed appropriately, says Jugna Shah, MPH, president of Nimitt Consulting in Washington, DC.

“To me, this is just a roundabout way of saying that start and stop are required in order to validate the billing and payment,” says Shah.

Correct charge capture
Each facility captures chemotherapy and other injection and infusion charges in a different way. At some facilities, health information management (HIM) department staff members or coders may capture charges. At others, a combination of the HIM department and clinical staff members may do so.

“There's no one right solution to the charge capture question in my experience,” Shah says. “It seems to depend on volume of patients/visits, staff knowledge and/or capacity, organizational culture, and ability to hire new staff, etc.”

At MD Anderson nurses are responsible for submitting the charges, but clinical billing specialists audit 100% of the documentation and correct any charge errors that have been submitted, Lewis-Patterson says. The facility currently uses an electronic module to record charges, but in the past used a paper charge ticket.

Each section of a charge ticket was color coded. For example, if the initial treatment was for chemotherapy greater than 15 minutes, everything on that charge ticket was red. For non-chemotherapy agents that were less than 15 minutes, the ticket was a different color. “We were able to go step by step and look at each one of the sections,” Lewis-Patterson says. “We followed the paper ticket in the way that maybe nurses think—or maybe the way that Anderson nurses think.”

Clinical and coding staff worked together to determine the best way to capture the charges at MD Anderson. In June 2008, MD Anderson implemented an infusion charge module. In the module, nurses first document chemotherapy greater than 15 minutes. The module also includes areas to capture  chemotherapy infusion 15 minutes or less, premedication, chemotherapy pushes, etc.

Another section of the module  gives MD Anderson nurses the opportunity to capture non-chemotherapy agents that are greater than 15 minutes, non-chemotherapy agents less than 15 minutes, and hydration. 

The beauty of this module is that the nurses do not need to know CPT codes. “We couldn't pick a CPT code out in a line up if you asked us,” Lewis-Patterson says.

The CPT codes are built into the module. When the nurse submits charges, a clinical billing specialist reviewed them. MD Anderson’s clinical billing specialist  really don’t have to memorize CPT codes at all, Lewis-Patterson adds. “They review the nursing  documentation to ensure that the documentation supports charges submitted.”

Some electronic tools can help with charging, whether it’s done at the point of care by clinical staff members or whether it’s entered in by someone else at a later time based on documentation, Shah says. “The best thing about smart tools is that they can result in not having to memorize the codes, the hierarchy, or the rules, and may be a huge relief for your clinical staff— especially for nursing staff— if they’re charging at the point of care.”

It can also result in lower compliance risk and fewer revenue leaks, but facilities need to make sure those electronic tools have all of the hierarchy rules and everything else built-in correctly, otherwise they could run into some problems, Shah says.

Coding examples
For example, a patient comes in to the infusion clinic. The physician orders the following medications:

  • Non-chemotherapy/pre-medications
    • Decadron® 8 a.m–8:20 a.m. (20 minutes)
    • Zofran® 8:20 a.m.–8:35 a.m. (15 minutes)
    • Ativan® 8:35 a.m.–8:50 a.m. (15 minutes)
  • Chemotherapy
    • Carbo® 9 a.m.–12 p.m. (3 hours)
    • Taxol® 12 p.m–1 p.m. (1 hour)
  • •Hydration at 500 cc per hour from 7 a.m.–3 p.m. (8 hours)

The nurse documents that hydration ran from 7 a.m. –3 p.m. However, the nurse administered all three pre-medications between 8:20 a.m–8:50 a.m. The nurse documented chemotherapy administration from 9 a.m. –1 p.m. (4 hours).

In turn, the clinical billing specialist will review the documentation and code based on what the nurse documented, not what the physician ordered, Lewis-Patterson says. In this example, the billing specialist would report three hours of hydration in addition to chemotherapy and IV pre-medications.

In another example, the nurse documents that the patient received one hour and 20 minutes of hydration outside of the time the patient received other chemotherapy and non-chemotherapy pre-medication. Even though the nurse documents one hour and 20 minutes of hydration, the clinical billing specialist will only bill for one hour to comply with CPT coding guidelines.

Good and bad documentation
So what does MD Anderson’s clinical billing specialist—or any coder or biller—need to see in the documentation? In addition to start and stop times, in a chemotherapy area, nurses need to document patient reactions to the chemotherapy.

Nursing documentation must clearly tell the story regarding  signs or symptoms observed, treatment given, how the patient tolerated the treatment, etc.  If the patient had a reaction, the nurse must document stop time, any nursing interventions,  chemotherapy  stop and restarted times, etc.  In this instance stop and restart times are essential, Lewis-Patterson says.

Continue to make documentation your number one priority, says Shah. “You definitely want to verify and have a process to validate using the documentation. You want to be able to work with staff quickly to resolve edits and then to provide feedback, especially if you've still got specific staff members that might be having some difficulty charging or with some documentation.”

Communicate between departments
Communication between departments is critical, not only to resolve problems after nurses submit documentation, but also to make nurses aware of what coders need. The clinical billing specialists  will  schedule unit rounds focused on  the  subject of the month for example missing documentation  regarding a reaction.  

Lewis-Patterson oversees six clinical areas with six clinical billing specialists assigned to each one of the areas. The nurses have been very receptive to charge capture  training. Acknowlegment of the various charge capture trainings  are noted  employee files she adds. 

In addition, when new nurses are hired into the ambulatory treatment center,  one of the  orientation modules they must complete is charge capture guidelines, policies, and procedures. 

Training shouldn’t stop after orientation, Shaw says. Provide refresher education and training to charging and coding staff using clinical examples that reflect your facility’s most common cases, she suggests.

E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at

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