Oncology & Hematology Coding Alert

Question: A patient who was diagnosed with lymphoma and advised chemotherapy visited our physician for a second opinion. She independently sought to have the reports reviewed. She wanted to confirm if she can begin the chemotherapy advised. Can we bill this as a consultation?

Florida Subscriber

Answer: You should ideally not consider this encounter a consultation. According to the CPT^® section notes for consultations, the physician who established the diagnosis and advised treatment did not refer the patient for an opinion. Your provider is under no obligation to send a written report to the physician. You should not code this as a consultation, but rather, use a new patient code from among 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient …).

What is a consultation? By definition, according to CPT^®, a consult is “a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.”

For this visit to qualify as a consultation, there should have been a verbal or written request for an opinion from the other physician. Depending on the payer, you don’t necessarily need a letter from the other provider, but there should at least be a note in the record stating that the patient has been referred for evaluation of special complaints or results of investigations. After the visit, a consultation would require a written report back to the requesting physician explaining the opinion that was requested.