Oncology & Hematology Coding Alert

From time to time there is uncertainty over whether a patient encounter is a consult or an office visit. In the case of a physician seeking the consult of another physician in the same group, some billers are reluctant to code for a consult. They are concerned that payers would consider the patientfor billing purposesin the care of the entire physician group.

As long as the consulting physician in the same group meets the requirements of a consult, he or she can bill for a consult, says Elaine Towle, CMPE, practice administrator for the New Hampshire Oncology-Hematology in Hooksett, NH. A consultation is eligible for payment when all of the criteria for the use of a consultation code are met, regardless of whether referring and consulting physician are members of the same practice, says Towle. She adds that the medical record should identify the problem that requires the need for a consult; it should support the level of consultation code by describing the extent of history, exam and medical decision-making required; it should include the consultants findings.

Under Medicare rules, carriers will pay for a consultation if the referring physician has not transferred the responsibility for a patients care to the receiving physician. Medicare does not consider a patient under the care of a consulting physician simply because the patients record is held by the physician group in which the consulting physician is employed.

For example, an oncologist in a multispecialty group practice can safely bill for a consult if a primary-care physician (PCP) within the group seeks the oncology physicians medical expertise. After the consulting physician assumes responsibility for the patients care that subsequent visits should be reported as an established patient office visit. For example, established patient visit codes should be used if the consulting physician finds a tumor in a female patients breast, recommends a course of treatment and the referring physician transfers responsibility for carrying out the new treatment plan to the consulting physician.

When a PCP in a multispecialty practice seeks the consult of an oncologist within the same practice, the use of a consult code is cut and dry. There is no question that the PCP is seeking expertise outside his or her own expertise.

But when an oncologist seeks a consult with another oncologist within the same group can be a bit more tricky, says Rebecca Dawson, CPC, a compliance education specialist for an academic medical center in Ohio. You have to prove necessity. For example, you need to show that the consulting oncologist has a subspecialty.

To prove medical necessity in this situation, the physician can refer back to the consultation guidelines: The medical record should show the problem that is necessitating [...]