Oncology & Hematology Coding Alert

Question: I work with a private oncologist who left a group practice last January. We saw a patient from that practice for the first time in November 1999 and a second time in August 2000. We do not have access to her previous records, and because this is only the second visit, her medical history is unfamiliar. A complete history was taken again. Is the patient new or established?

Georgia Subscriber

Answer: This patient is an established patient. A new patient is one who has not received any professional services from the physician or another physician in the same group practice within the last three years. This patient clearly has received care from the physician or a former colleague within that time. Although this physician has left a group of oncologists, has entered independent practice and may have been assigned a new provider number, he or she has examined this patient in the recent past.

Although the extensive history and the subsequent time demands may have been avoided if the patient requested her records from the other practice, the other practice may not release the records directly to the private physician. That request needs to come from the patient in person and most commonly with a signed release. The patient has a right to a copy of her records.

The physician still has the opportunity to bill an evaluation and management (E/M) service for an established patient (99211-99215). The three key components in selecting a level of E/M services are history, examination and medical decision-making. Because the typical work-up for a cancer patient includes a comprehensive history and examination, two of the three key components are met to allow a 99215 visit to be billed.

This question was answered by Margaret Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant and former clinical director at Tulane Cancer Center in New Orleans.