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.

  • 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.
  • Though regulations vary by state, services delivered by advanced practice providers may also be reportable and reimbursable.

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.

Below are CPT ® codes for services that may be provided as part of the long-term care of cancer survivors:
**ASCO strongly recommends you verify appropriate CPT® codes with your local Medicare Administrative Contractor (MAC) and other insurance plans held by your patients.**

Developing the Treatment Plan and Summary Care Plan

  • 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

Note: These HCPCS codes may only be reportable to Medicare unless otherwise directed by a private payer.

Monitoring for and Managing Physical Late Effects: Evaluation and Management (E/M) Services

  • 99211 - Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal
  • 99212 - Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.
  • 99213 - Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.
  • 99214 - Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.
  • 99215 - Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.

Providing Health Education

  • 99417 - Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time.
  • 99354 – Prolonged E/M with Direct Patient Contact ; 1st hour (30-60 min)
  • 99355 – Prolonged E/M with Direct Patient Contact; Each Add’l 30 min
  • 99358 – Prolonged E/M, Without Direct Patient Contact; 1st hour (30-60 min)
  • 99359 – Prolonged E/M, Without Direct Patient Contact; Each Add’l 30 min

Note: Due to the creation of CPT code 99417, CPT codes 99354, 99355, 99358, and 99359 may no longer be reported with office or outpatient E/M services (99202-99215)

Behaviour Change Interventions

  • 99406 – Smoking and tobacco-use counseling, 3-10 minutes
  • 99407 – Smoking and tobacco-use counseling (intensive), greater than 10 minutes

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