Oncology & Hematology Coding Alert

Question: If our physician only reviews patient records, but doesn't actually examine the patient, may we bill a consult (assuming the payer accepts consult codes)?

Oregon Subscriber

Answer: Before you report a consult code, you need to be sure the service meets the requirements, including:

• Written request from a physician or other appropriate source
• Medically necessary reason for the consultation
• Face-to-face history, exam, and medical decision-making (MDM) rendered by the physician for the patient's problem
• Written report sent to the requesting physician with recommendations regarding the patient's care.

If your physician does not see the patient, you have no face-to-face encounter to bill and therefore cannot report a consultation (such as 99241-99245, Office consultation ...).

Time exception: If the physician sees the patient and does not perform an examination, but the visit qualifies otherwise as a consultation, you may be able to code based on time. The physician would have to document face-to-face counseling and/or coordination-of-care activities dominated the visit to meet the time-based coding criteria. Your physician's documentation would then need to specifically outline the counseling's content and coordination of care. He also should document the total time with the patient and the percent of time he spent on counseling and coordination of care (it must be more than 50 percent of the entire visit to report an E/M service based on time).

Pick your level: After that, you should pick the code level based on the typical time included for each E/M code. For example, the definition of 99242 (Office consultation for a new or established patient ...) indicates the typical time is 30 minutes. You may not go to a higher code level until the physician equals or exceeds the total time for that code, according to CPT®.

Final note: As your question mentions, many payers no longer accept consult codes. That includes all traditional Medicare payers. For those payers, you should report a relevant E/M code rather than a consult code.