Oncology & Hematology Coding Alert

Question: I know that a nonphysician practitioner and an oncologist can "share" an E/M visit, with the nurse, for instance, taking the history and performing some preliminary work and then handing off the patient to the oncologist for the exam. Does this apply for consultation services, as well?

New Jersey Subscriber

Answer: Coding experts and CMS regulations agree: You cannot bill consults as "shared visits."

Specifically, the CMS definition of a shared visit says the service must follow all the rules of an "incident-to" office service -- which means that there should be an established patient with an established problem. And, generally, these aren't the circumstances with a consult.

Regardless of the patient's status, however, when a requesting doctor asks for a consult, he is only seeking your oncologist's opinion, not the opinion of other providers in your office.
Example: The oncologist believes consultations for three patients will take up to 45 minutes each, so he sends the NPP to obtain background information. When the oncologist goes in, he takes care of the end portion of each visit. In this case, you cannot report the consultations under the oncologist's NPI -- even if the service otherwise meets the requirements of a consultation -- because the oncologist did not perform the entire service.

Bottom line: Payers and the HHS Office of Inspector General are scrutinizing consults, and you shouldn't place your claims in jeopardy by violating "shared visit" criteria.

Best practice and ethics dictate that the consulting physician should provide the entire service if he wishes to report a consultation.

He should not rely on the work or opinions of NPPs (who cannot meet the requirements of a consultation service) when reporting either outpatient (99241-99245) or inpatient (99251-99255) consultations.