Oncology & Hematology Coding Alert

Sharing the inpatient consult with an NPP could result in a 15 percent reimbursement cut

The month of May inspires thoughts of summer sunshine and, unfortunately, melanoma--it's National Skin Cancer and Detection Month. We-ll clear up how to code for one common aspect of melanoma care: the consult.

Dermatologists and surgical oncologists often treat melanoma patients, but other physicians may send patients to your medical or radiation oncologist for a consult to determine whether the patient needs further treatment.

ICD-9 note: Oncologists usually see patients for consults after they have a positive pathology, says Elaine Towle, CMPE, program director for Oncology Metrics in Ft. Worth, Texas. That means the documentation should reveal a confirmed diagnosis.

Example: A patient with a confirmed diagnosis of malignant melanoma of the back arrives for a consult. The neoplasm table entry for -Melanoma- is -See Melanoma.- You look up -Melanoma- in the alphabetic index, which indicates 172.5 for back melanoma. You check the tabular index and determine 172.5 (Malignant melanoma of skin; trunk, except scrotum) is the correct code for your claim.

Expect Denials for -No Reason-

To count on consult reimbursement, you must make sure the requesting physician's original consultation request specifies why the patient needs the service, according to MLN Matters article MM4215 (www.cms.hhs.gov/MLNMattersArticles/downloads/MM4215.pdf). And be sure that original request is in the patient's medical record.

Likewise, the consulting physician--the oncologist--needs to document this reason. Then, the oncologist must document both the exam and the opinion he renders, and he must send a report of his findings and opinion back to the requesting physician.

Example: A dermatologist suspects that his patient who has malignant melanoma of the thigh (172.7, Malignant melanoma of skin; lower limb, including hip) might benefit from chemotherapy. While the patient is admitted to the hospital, the dermatologist requests an evaluation from a medical oncologist. In the consult request, the dermatologist documents his reason and records the request in the patient's medical record.

The oncologist performs a level-three consult (99253, Initial inpatient consultation ...) and decides the patient would not benefit from chemotherapy at this time. The oncologist documents the reason for the dermatologist's request and any advice he renders, and then he reports this to the dermatologist with a note to continue monitoring the patient.

Watch Out for New NPP Rules

If your oncologist sends his nonphysician practitioner (NPP) to take care of the preliminary workup for an inpatient consultation, he could be cutting out 15 percent of his usual reimbursement. You-ll have to code the service under the NPP's name and number for Medicare patients.

Why? The shared/split visit does not apply to consultation services, says Cynthia Swanson, RN, CPC, senior management consultant for Seim, Johnson, Sestak & Quist LLP in Omaha, Neb.

Consults can't be reported as split/shared E/M visits, according to MM4215.

Example: The oncologist believes consultations for three patients will take up to 45 minutes each, so he sends the NPP to obtain background information. When the oncologist goes in, he takes care of the end portion of each consultation visit.
 
You cannot report the consultations under the oncologist's UPIN/PIN. Because the NPP participated in the consultation visit, you-ll have to report the consultation under the NPP's UPIN/PIN and -receive 85 percent of the Medicare-allowed amount for the NPP's work,- says Nancy Lynn Reading, RN, BS, CPC, a coding educator with University Medical Billing at the University of Utah in Draper.

Rule of thumb: If the NPP participated in the consult service, you have to report it using the NPP's UPIN/PIN. If the oncologist provides the entire consult service, you should report it under the oncologist's UPIN/PIN.

Avoid Consult Code for Transfer of Care

If the consulting oncologist immediately arranges a treatment plan, the visit may be riding a fine line between a new patient E/M and a consult.

Example: A melanoma patient presents for a consultation with a radiation oncologist who determines the patient would benefit from palliative radiation therapy. Because of the advanced nature of the disease, the radiation oncologist takes over the care of this patient. That is, he sets up a plan of care for this patient and does not return him to the requesting physician's care for treatment of a specific condition.

Report this encounter as a new patient E/M, such as 99204 (Office or other outpatient visit for the evaluation and management of a new patient ...).