Oncology & Hematology Coding Alert

Question: May I code a consult when oncologist A requests a consult from oncologist B?

Utah Subscriber

Answer: Yes, physicians of the same specialty may request and receive consultations (99241-99245, outpatient; or 99251-99255, inpatient) from one another.

CMS's MLN Matters article MM4215 clarifies that a physician may provide a consultation for another physician of the same specialty (www.cms.hhs.gov/MLNMattersArticles/downloads/MM4215.pdf). The service must meet two minimum conditions, however:

1. Documentation must verify all elements of a consultation service, including a request for consult in both the requesting and consulting physician's record, a reason for the consult request, and a written report from the consultant to the requesting physician outlining the consultant's findings and recommendations.

2. The consulting physician's knowledge and expertise must go above and beyond that of the requesting physician. In other words, the physician in the group being asked for the consultation must clearly have a skill set that the requester does not have. The chart must reflect the reason and justification (medical necessity) for the consult.

Watch out: The same practice cannot report two inpatient consultations for the same patient during the same hospital stay.

For instance, if an oncologist admits the patient and consults with a partner who has more experience in that specialty, the partner can bill a consult (although you may have trouble getting paid for both doctors on the same day).

If, however, oncologist A provides an inpatient consult for another physician and then requests a consult from more experienced oncologist B in the same practice, you may not report the second visit as a consultation.