Location of Services

Coverage and reimbursement services for the long-term follow up care of survivors of cancer will be directly related to the program model of survivorship care at your facility. For example, hospital-based programs may be able to offer the majority of services in-house while providers working in private practice may be able to provide some services in-house, but refer survivors to other facilities for some services. Other models will offer a combination of internal and external services, with some services provided in-house and others provided at outside facilities.

Determining the services provided should be based on patient need. Using the Survivorship Care Plan as a guide is an effective way of communicating with the patient regarding their personal cancer treatment history, appropriate follow-up screenings, surveillance for recurrence, and the possibilities of late- and long-term effects from treatment.

Reimbursement

  • Currently, there are no established billing codes categorized specifically for survivorship care.
  • Follow-up visits are routinely covered by payers, but not all survivorship providers can bill in all states.
  • Oncologists may be able to bill for the total time spent examining and/or counseling the patient. Further, though regulations vary by state, services delivered by advanced practice providers may also be reportable and reimbursable.

All coverage and reimbursement is subject to Medicare, Medicaid, and third-party payer benefit plans. Therefore, ASCO strongly encourages you to verify with the patient’s insurer to understand what type of services will be covered. It may be possible to discuss the long-term care plan with the patient’s insurer to determine if services would be recognized and/or covered. There may also be an opportunity to discuss the need for this type of care delivery during contract negotiations.

Below are possible billing codes for services that may be provided as part of the long-term care of cancer survivors:

**ASCO strongly recommends you verify proper billing codes with your local Medicare administrator and other insurance plans held by your patients.**

Developing the Treatment Plan and Summary Care Plan

The following codes are temporary codes and are not recognized for reimbursement by Medicare or Medicaid:

  • S0353 – Treatment planning and care coordination management for cancer; initial treatment
  • S0354 – Treatment planning and care coordination management for cancer; established patient with a change of regimen

While reimbursement is currently not available for the completion of the Survivorship Care Plan—composed of the treatment summary and long-term care plan—ASCO and others are actively working on legislation to enable providers to bill for this service.

Monitoring for and Managing Physical Late Effects

  • 99211 – Office or other outpatient visit for the evaluation and management of an established patient, which may not require the presence of a physician. Typically 5 minutes are spent performing these services.
  • 99212 – Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 components: a problem focused history; a problem focused examination; straightforward medical decision making.
  • 99213 – Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity.
  • 99214 – Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 components: a detailed history; a detailed examination; medical decision making of moderate complexity.
  • 99215 – Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 components: a comprehensive history; a comprehensive examination; medical decision making of high complexity.

Providing Health Education and Promotion Counseling 

  • 99354 – Prolonged Direct E/M; 1st hour (30-60 min)
  • 99355 – Prolonged Direct E/M; Each Add’l 30 min
  • 99358 – Prolonged E/M, Patient Not Present; 1st hour (30-60 min)
  • 99359 – Prolonged E/M, Patient Not Present; Each Add’l 30 min
  • 99406 – Smoking and tobacco-use counseling, 3-10 minutes
  • 99407 – Smoking and tobacco-use counseling (intensive), greater than 10 minutes

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