Oncology & Hematology Coding Alert

Question: To bill confirmatory consultations, I thought all I needed was a patient's request for a consultation, not a requesting physician's. But our payer has denied our claim, stating that we need a requesting physician's request. What should I do?

Oklahoma Subscriber

Answer: When you report confirmatory consultation codes (99271-99275), make sure your documentation clearly shows that a patient, family member or third-party payer asked the consulting physician to evaluate a treatment plan or surgery another physician has prescribed.

In other words, document that the patient, family member or third-party payer has requested a second opinion. To prevent denials, you may want to supply additional information with your confirmatory consultation claims. For example, you could send a copy of CPT's consultation guidelines on page 14 of the 2004 professional edition. And, if a third-party payer requests a confirmatory consult, you should attach modifier -32 (Mandated services), according to CPT guidelines.

Remember that Medicare claims require certain information regarding the physicians: For instance, you should submit the oncologist's unique physician identification number (UPIN) information in item 17 and 17A of the CMS-1500 claim form or the corresponding electronic field.

When the patient requests the confirmatory consult, you would supply the consulting physician's UPIN and name in items 17 and 17A.