Oncology & Hematology Coding Alert

Question: I work for a fairly large oncology practice. We currently have medical oncology and radiation oncology doctors, and they are considered subspecialties from each other. We have an oncology surgeon starting in a few weeks who will work directly for our practice. My question is this: Is surgical oncology considered a separate subspecialty from the other two?

AAPC Forum Participant

Answer: Yes — per Medicare guidelines, all three subspecialties are regarded as separate entities:

• Physician/medical oncology has a Medicare specialty code of 90 and a provider taxonomy code of 207RX0202X.
• Physician/surgical oncology has a Medicare specialty code of 91 and a provider taxonomy code of 2086X0206X.
• Physician/radiation oncology has a Medicare specialty code of 92 and a provider taxonomy code of 2085R0001X.

Such distinctions are vitally important when properly setting up the credentialling of the new provider and in determining if a patient is new or established to your practice. CPT® defines an established patient as “one who has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years” (emphasis retained).

So, any patient seeing a physician in one subspecialty for the first time would be regarded as new to your practice even if they had previously been seen by another physician in your practice in one of the other two subspecialties within the past three years.

This, in turn, becomes important, as payments for new patients receiving office/outpatient evaluation and management (E/M) services from a provider in your practice will be higher than payments for established patients. New patients receiving a level three office/outpatient E/M, for example, are currently reimbursed at the national, nonfacility rate of $111.51 per the 2024 Medicare Physician Fee Schedule (MPFS), while the 2024 MPFS reimburses established patients at the national, nonfacility rate of $90.87 for the same level of service — a difference of $20.64 for each new patient your practice sees.