Oncology & Hematology Coding Alert

Question: My understanding is that when billing for a consultation, the choice of words in the documentation needs to be very specific to differentiate between a consult and a referral. What documentation is needed, and how should it be worded to ensure we are within Medicare guidelines for billing a consultation?

Indiana Subscriber

Answer: Determining whether a visit is a consult or a new patient visit is a common question. Generally, oncologists should bill the patients first visit as a consult (99241-99245).

Certain elements, however, must be present for an oncology practice to bill appropriately for a consultation. If, for example, the oncology practice fails to document that an opinion was rendered, the practice has no choice but to bill it as a new patient visit (99201-99205).

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

1. The patient visit involves the physician endering an opinion.

2. Documentation must show a request from the patients previous physician and a need for consultation.

3. Documentation must show that a written report of the consulting physicians findings was prepared and sent to the referring physician.

4. Documentation must show that the consultation does not involve active management of the patients 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.
Patient-generated confirmatory consultation.

Language included in the request for consultation should be clear in stating that the visit is a consultation, not a transfer of care in which full responsibility of the patients complete care is undertaken by the receiving physician.

The request for a consultation should include the source of the request, and the reason for the consult should be documented in the patients medical record.

Tip: Consultations requested by members of the same group are covered. They must also meet the requirements listed above.

This question was answered by Elaine Towle, CMPE, practice administrator for New Hampshire Oncology-Hematology in Hooksett, N.H.