Oncology & Hematology Coding Alert

When an oncology physician sees a patient for the first time, erroneously coding the exam as a new visit versus a consult can cost practices an average of $30 per appoint-ment. Add that up over the course of a year and that can translate into losses of thousands of dollars.

In general, patient visits that are the result of physician referrals should be coded as consultations (99241-99245) and patients who self-refer should be considered new, says Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett, N.H.

For example, a visit that was prompted by the referral of a primary care physician after a routine screening showed a positive result should be coded as a consult. On the other hand, a patient who has moved to the area and has a history of cancer and asks a physician to assume followup care should be coded as a new patient (99201-99205).

Key Elements of Coding a Consult

Specific criteria must be met in order for oncology practices to code an evaluation and management (E/M) service as a consult. (Note: Failure to meet these requirements forces oncology practices to code the first visit as a new patient exam, rather than a consult and lose deserved reimbursement). Medicare has established the following guidelines in the Medicare Carriers Manual, Section 15506:

Request for Opinion: The patients physician must make a written or verbal request. A physician service initiated by a patient and/or family, and not directly requested by the patients attending physician, may not be reported using the initial consultation codes, but may be reported using the codes for confirmatory consultation, 99271-99275, or new patient office visit codes;

Reason: Medical necessity for a consult must be proven. In most cases an abnormality that has the potential for a cancer diagnosis is sufficient;

Recording: All tests and services performed must be documented in the patients medical record; and

Reporting: The same tests and services, with the consulting physicians findings, must be communicated to the referring physician in a written report.

Determining Complexity

Like all other E/M services, office consults are governed by three key components history, exam and medical decision-making. Unlike office visits, which must meet two out of three factors to bill higher levels of service (99212-99215), office consults require that all components be met.

For example, a physician must perform a comprehensive history and examination and show that medical decision-making was of moderate complexity to code the consult as a level four 99244. The following outlines the factors to consider for medical-decision making:

1. History
The background obtained from the visit includes reviews of the chief complaint; extended history of the present illness; review of systems directly related to the problems identified in the history of the present illness; and a complete past, family and social history.

2. Exam
The examination must include a general multisystem exam or complete examination of a single organ system. Moderate complexity of medical decision-making is determined by the presence of two of the three following factors:

Multiple diagnoses or management options;
A moderate amount of data reviewed or moderately complex data reviewed; and
A moderate risk of complications and/or morbidity and mortality.

Note: See the April 2000 Oncology Coding Alert for ways to determine moderate complexity, data and risk.

3. Documentation
Getting physicians to comply with improved documentation initiatives can involve lengthy educational programs, which sometimes have limited results. In the absence of sound notations in the patient record, both Cothern and Towle remind coders that an excellent description of medical decision-making should exist in the written report to the referring physician.

The patient record should indicate the following:

For a presenting problem with an established diagnosis, it should reflect whether the problem is improved, well-controlled, resolving, resolved inadequately controlled worsening, or failing to change as expected. Problems that are improving or resolving are less complex than those that are worsening or failing to change as expected.

When a presenting problem is without a diagnosis, oncologists should state their clinical impressions in the form of a differential diagnosis or as possible, probable or rule out diagnosis.

A decision to obtain old medical records or history from sources other than the patient should be documented with relevant findings.

Note: The guidelines for medical decision-making can be found in Table 2 on page 7 of the 2001 CPT.

Within the report to the oncologist, the physician will have described the problem, the nature of the examination, tests performed and their results, a description of the physicians findings, and detailed advice about future medical care the patient will need.

Transferring Care

If the primary physician, oncologist and patient agree on a course of treatment and the oncologist assumes care, all office visits subsequent to the consultation are coded as established patient visits (99211-99215). Towle says practices sometimes make the mistake of coding the next visit as a new patient visit. Medicare and CPT guidelines define a new patient as one who has not received any professional services from the physician, or another physician of the same specialty that belongs to the same group practice, within the past three years.