Oncology & Hematology Coding Alert

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.


Question: A patient came in for an initial office visit, which we coded as 99243 (office consultation for new or established patient) with a diagnosis of 611.72 (lump or mass in breast). We scheduled the patient for a breast biopsy, 19120, but we did not post charges until the pathology report came in so we could use the final diagnosis code. In this case, the patient was diagnosed with breast cancer (174.x-175.x). In a couple of days, the patient returned to the office for a cancer consultation.

According to the CPT book, we should use 99215 (established patient office or other outpatient visit), but which modifiers do we use if the cancer consult falls in the global period of the biopsy?

After a lengthy consultation, the patient decided on mastectomy, and we coded it as 19240-58 (mastectomy; with modifier for staged or related procedure or service by the same physician during the postoperative period). How do we code the cancer consultation between the biopsy and mastectomy? Should we hold biopsy charges for final diagnosis and use the cancer diagnosis code for consult and mastectomy?

Austin Surgeons
Austin, Texas


Answer: You must code the reason for the encounter. For the initial office consultation visit, for example 99243, use diagnosis code 611.72 for the breast mass and also for the biopsy because at that time you didnt know the patient had cancer.

Coding for postoperative services can be confusing. According to some payers, when the patient returns to the office to discuss the results of the surgery and surgical options, no code should be assigned because this is part of the postoperative management, and only unrelated visits can be coded during the postoperative time.

Other payers will pay for the visit, so check with all of your popular third-party payers to see what they consider unrelated. Does it depend on body site or diagnosis? If the payer will reimbursement you, code the appropriate level of service 99211-99215. Choose the code that reflects the documentation in the record.

If the physician spent a prolonged amount of face-to-face time with the patient, use add-on codes 99354 and 99355 (prolonged physician service with direct [face-to-face] patient contact) as appropriate. Be sure to deduct the part of the visit time that was used to discuss the previous surgery because that time would be included in the postoperative time.

The diagnosis for this visit would be the cancer diagnosis, which is a separate diagnosis from the initial visit. Append modifier -24 (unrelated evaluation and management [E/M] service by the same physician during a [...]