Oncology & Hematology Coding Alert

If a patient who has recently been diagnosed with cancer presents for a second opinion, how should that visit be coded new patient visit (99201-99205) or confirmatory consultation (99271-99275)?
 
Confirmatory consults are low-paying office visits, so it is important for oncology practices to choose not only the most appropriate code but the code that will provide the fairest reimbursement. Dont automatically code the visit as a confirmatory consult simply because the patient comes in for a second opinion.

 
The purpose of a confirmatory consultation is to obtain a specialists guidance and recommendations regarding a previous diagnosis, evaluation, and/or treatment plan given by an attending physician.
 
The consulting physician should only render an opinion for a confirmatory consult, says Stephanie Thompson, CPC, practice manager for Lexington Oncology Associates, an oncology practice in Kentucky.
 
In most cases, this requires the review of records and test results from the patients attending physician. According to Medicare regulations, confirmatory consultations may be provided in any setting and consist of: history, exam and medical decision-making. If the consulting physician is aware of the confirmatory nature of the opinion sought 99271-99275 must be used. Choose the appropriate code based on the three key components listed above.
 
Confirmatory consultation codes are appropriate  when an insurer, as part of its internal policy, sends one of its clients for a second opinion. Much like the situation described above, where  the attending physician refers the patient to another oncologist for an opinion, the insurance company is also seeking the opinion of a second oncologist. In this case, modifier -32 (Mandated services) is appended to the appropriate confirmatory consultation code to indicate to the payer that the service was required.
 
If the patients attending physician requests a consult, the procedures are similar to that of an office consultation a written or verbal request must be made to the consulting physician, and a report must be prepared by that doctor and provided to the attending physician, says Lillie McAllister, CPC, president of Double-Diamond Enterprises, a coding and consulting firm in Conroe, Texas.
 
Like an office consultation (99241-99245), the request must be documented as an order in the attending physicians note or in a signed consult sheet requesting information. The written report from the consulting doctor should be provided to the attending physician for inclusion in the medical record.

 
Often, the patient independently seeks a second opinion without referral from the attending physician. Because the patient was not referred, codes other than confirmatory consultation codes may be used.
 
For example, new office visit codes (99201-99205) may apply. To use them, the second (consulting) oncologist must take over the management or treatment of the patient. This sometimes happens when after visiting with the consulting physician the patient decides he or she likes that doctor better and requests the physician to assume care, Thompson says. The consulting physician should state in his or her report that the patient came in seeking an independent second opinion.
 
Codes 99201-99205 may also be used if the patient independently seeks the second opinion and the physician provides more than advice or opinion. For example, the consulting physician may administer a new battery of tests to determine his or her diagnosis.
 
If the service provided results in the physician assuming the patients care, any subsequent services to the original advice or opinion should be coded using the appropriate established patient visit codes (99211-99215), or subsequent hospital care codes (99231-99233) if the initial consult visit occurred in a hospital.