Oncology & Hematology Coding Alert

Question: Do you bill a patients first office visit with an oncologist as a consult or new patient office visit?

Deborah Lief, CPC
ProMedCo, Fort Worth, Texas

Answer: There are specific guidelines oncology practices must follow before billing the patients first visit as a consult (99241-99245) or a new patient office visit (99201-99205). The differences drive reimbursements levels. Payments for consults are significantly higher than the other evaluation and management (E/M) services coded at the same level because of the additional work involved.

Practices must be sure that the following four documentation elements are present in order to distinguish a consult from other services:

- the patient visit involves the physician having to
render an opinion;

- a request from patients previous physician and a
need for consultation;

- that a written report of the consulting physicians findings was prepared and sent to the referring physician;

- that the consultation does not involve active management of the patient problem. Diagnostic and/or therapeutic services, however, may be initiated.

Elements that do not meet the consultation criteria:


- Standing orders in the medical record for consultation;

- No order for a consultation;

- No written report of consultation back to the requesting physician;

- Patient-generated confirmatory consultation.

Medical billing staff should also be careful in ensuring there was not a transfer of care in which full responsibility of the patients complete care is taken over by the receiving physician at the time of referral. In this case, the physician would bill for a new patient visit (99201-99205) or an established patient visit (99211-99215). Transfer of care occurs when the transferring physician turns over responsibility and the receiving physician documents the approval of care in advance

The request for a consultation, the source of the request, and the need for a consult must be documented in the patients medical record. Consultations requested by members of the same practice group are covered if one physician in a group practice requests a consult from another in the same practice. The consulting physician still must meet the requirements listed here.

Editors note: The answer to this coding question was provided by Elaine L. Towle, CMPE, practice administrator at New Hampshire Oncology-Hematology in Hooksett, N.H. She is also past president of Administrators in Oncology-Hematology Assembly of the Medical Group Management Association.