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Oncology & Hematology Coding Alert

Reader Question:

Discussing Treatment Options

Published on Fri Dec 21, 2012

Question: A patient came for a consultation. The next week the patient came back to further discuss treatment options and so forth, but there was no physical exam. How do I bill for this visit?

North Carolina Subscriber

Answer: You should bill for the first visit with the appropriate code from the 99241 through 99245 range (office consultation for a new or established patient). For the second visit, there are two options. The first option is to determine the evaluation and management (E/M) level, based upon the extent of documentation of the three key components of history, exam and decision-making. The second option arises if the visit qualifies as one where time is the key or controlling factor to qualify for a particular level of E/M service. From your description, this visit meets the criteria for making time the controlling factor.

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