Oncology & Hematology Coding Alert

In August 1999, HCFA added a definition of consultations (99241-99275) to the Medicare Carriers Manual (MCM), a clarification that will prove useful to oncology coding professionals in determining when an oncologist has assumed responsibility for care of a cancer patient versus when they are actually performing a consultation. Financially this is very important, because the consult codes reimburse at a higher rate than the in-office or inpatient exam codes.

There are three key elements in a consultation:

1. a request for opinion or advice about a patient from one physician (or other appropriate source) to another;

2. performance and documentation of that service by the consultant; and

3. communication of the opinion or advice back to the requesting physician.

The previous, somewhat ambiguous, MCM explanation of consultations has been expanded from a few paragraphs to nearly three pages and includes helpful examples:

A. When a Consult Changes to Assumption of Care.

Consultation changes to assumption of care in one of two ways:

1.) When the physician (or other appropriate source) requesting a consultation transfers responsibility for complete care at the time of the request or

2.) visits subsequent to the initial consultation where the consulting physician is now managing a portion or all of the patients treatment.

The consulting oncologist may begin diagnostic or therapeutic services during the initial encounter with the patient even though that evaluation is billed as a consultation (99241-99275). After that point, the consultant has assumed care. Therefore, if the oncologist sees the patient again, that next visit will be billed as an established patient visit (99211-99215, outpatient; 99231-99233, inpatient).

For example, a surgeon sends a 60-year-old male patient with Stage III colon cancer to see a medical oncologist concerning possible chemotherapy following surgery. The oncologist orders a chest x-ray to rule out lung metastases. The initial visit is correctly billed as a consultation. The next visit, however, is billed as an established patient visit (MCM 15506, August 1999).

In the case of a patient with invasive ductal breast cancer, the surgeon who performed the biopsy and mastectomy probably would seek a consultation from both a medical oncologist and a radiation oncologist concerning the need for further treatment. Each oncologist would see the patient, most likely in the office, do an evaluation, and each would render an opinion concerning treatment. Each would respond to the surgeon, in writing, with the opinion. That would complete the consultation, which would be billed as an outpatient consultation (99241-99245).

B. Inpatient vs. Outpatient Consults.

The major difference between in- and outpatient consultations is the number of consults allowed.

1. Inpatient: According to CPT rules, the consulting physician is limited to one consult per patient per hospital stay. If there are several partners in the medical oncology group, the group can do only one initial oncology consultation per patient per hospital stay. But an oncologist might need several follow-up consultations (99261-99263) to complete his or her opinion because the patients case is complex or because test results are incomplete, and that is permitted. Once the oncologist has assumed care for that patient, consultation codes are closed. The oncologists next billing is for a subsequent hospital visit (99231-99233).

2. Outpatient: An outpatient consultation (99241-99245) is a single-step process. The consultant sees the patient one time, does an evaluation, and renders an opinion in writing. For example, consider a 30-year-old patient with advanced ovarian cancer sent to an oncologist by a gynecologist for a consultation. If after rendering an
opinion the oncologist continues to treat the patient, the oncologist has assumed care of the patient. The next visit becomes an established patient visit (99211-99215). There are no more consultation codes available unless another physician, not the gynecologist, requests a consultation. For example, the oncologist sends the ovarian cancer patient to see a colleague in his group practice, also a medical oncologist, and requests his opinion about the treatment regimen. The patient has not responded to the current therapy, which includes Cisplatin. The consultant does an evaluation and writes a recommendation to his colleague for a combination regimen of Herceptin and Taxol. Instead of consulting a colleague within his own practice group, the requesting oncologist might have sought the opinion of an outside consulting oncologist. What made the consultation necessary was the complexity of decision-making involved, not the site or the special expertise of the consultant.

C. Avoid Using the Term Referral.

Catherine Fischer, reimbursement policy advisor for Marshfield Clinic in Wisconsin and a national policy expert on E/M coding, supports HCFAs action in defining consultation without depending on reference to referral. That wordreferralis responsible for much of the confusion around consultation. Its widely used in medicine, but it isnt used in CPT and with good reason. You can refer for treatment. You can refer for a consultation. You can refer for a diagnostic test. Referral is an ambiguous term, and you need to avoid it in coding.
Consultants need to make clear in their response that theyve been asked for their opinion or advice: Dr. John Adams has requested my opinion concerning Mary Smiths adjuvant treatment for invasive ductal breast cancer, etc. Otherwise, there will be unnecessary confusion. Fischer adds, If you must use the term referral, distinguish it by linking it with the words opinion or advice. If you link the term referral with the word treatment, then you dont have a consultation.

Both the request and the need for a consultation must be documented in the patients medical record by either the requesting physician or the consultant.