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 [...]