Oncology & Hematology Coding Alert

Question:  When a patient sees the oncologist for a second opinion, which CPT^® code should we report?

Illinois Subscriber

Answer: You should report the appropriate office or hospital visit E/M code. For instance, if the oncologist meets with a new patient in the office and documents a comprehensive history, a comprehensive examination, and medical decision making of high complexity, you should report 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity ...).

Note that while 99205 is used here as an example, you should choose the appropriate E/M code supported by the documentation.

Tip: If the total counseling/coordination of care time comprises more than 50 percent of the physician-patient face-to-face time, you may select the E/M code based on time. Before doing so, make sure documentation indicates the total face-to-face minutes, the counseling/coordination of care minutes, and a brief summary of the counseling/coordination of care.

Watch for: If a third party requests a second opinion — for example, to confirm that recommended treatment is medically indicated — CPT^® indicates you should append modifier 32 (Mandated services) to the office visit code. Not all payers, however, accept modifier 32. For instance, it isn’t recognized as a payment modifier for Medicare.

Remember: While Medicare and many Medicaid payers no longer allow E/M consultation codes, private payers may still require you to report a second opinion/consultation using outpatient and inpatient consultation codes 99241-99255.