Oncology & Hematology Coding Alert

Billing for a consultation (99241-99245) requested by a physician in the same group may raise the eyebrows of of Medicare carriers and may even cause a denial. But if the consult meets Medicare's requirements, there is no reason why the practice shouldn't be paid.
 
"It can be hard if two physicians are in the same group," says Nancy Giacomozzi, office manager for P.K. Administrative Services in Lakewood, Colo., which serves oncology practices. "What the payer sees is the same diagnosis code and the same group practice number."
 
In most cases, the oncology practice that is denied for consultation services because it involves a request from a physician in the same group is justified in its billing and should not give up on the claim.
 
To win an appeal, the oncology practice must prove the medical necessity of the consult, says Imelda Lee, RHIA, CTR, coding supervisor with University Physicians Group at the University of Texas Health Science Center in San Antonio.

 
To prove medical necessity in this situation, the physician must follow consultation guidelines, which assert that the medical record must show the problem that requires a consultation. A practice's case is bolstered if the consulting physician within the same group had credentials that showed expertise in an area in which the attending physician is seeking advice.
 
For example, an oncologist requests a consult from a radiation oncologist in the same group to determine whether a patient should have radiation treatment.
 
If the consulting physician is outside of the treating physician's group, the patient record would include the reason for the consult, such as confirmation of a previous diagnosis. For a same-group consult, that documentation  should still occur but should also include a statement about the consulting physician's expertise so that on review, payers will understand the unique knowledge the consulting physician brings to the case, Lee says.
 
The patient record should also include notations from both treating and consulting physicians. This should be true in both same-group consults and outside-group consults. With same-group consults, physicians should take great care in distinguishing their notes from one another, Giacomozzi says. Notations by the treating physician should be clearly distinguishable from the consulting doctor to show the active involvement of both physicians.
 
Aside from sharpening documentation, practices should be sure to follow the general criteria for a consultation. If any one of the requirements is not met, practices will be forced to code for lesser E/M services, such as 99202 (office or other outpatient visit) because the patient encounter would have to be considered a new patient visit, rather than a consult.
 
Consults have four general criteria:

The patient's physician must make a written or verbal request. Consultations must be initiated by a physician. A "physician service" initiated by a patient and/or family, and not directly requested (in writing or verbally) from the attending physician to the consulting physician, may not be reported using the initial consultation codes, but may be reported using the codes for confirmatory consultations or office visits.
 

Medical necessity for a consult must be proven. In most cases, an abnormality with the potential for a cancer diagnosis is sufficient.
 

All tests and services performed must be documented in the patient's medical record.
 

The same tests and services, along with the consulting physician's findings, must be communicated to the requesting physician in a written report.

 
There are five levels of office consultation services, each with its own requirements. Code 99241, level-one office consultation, requires a problem-focused history, a problem-focused examination, and straightforward decision-making. But 99245, level-five office consult-ation, requires a comprehensive history, a comprehensive examination, and medical decision-making of high complexity.

 
Because of the risk associated with same-group consults, some oncology practices choose to use codes for a new patient visit. According to Medicare guidelines, a consultation is distinguished from a visit because it is done at the request of a requesting physician. Also, the consultant prepares a report of his or her findings, which is provided to the requesting physician for use in treating the patient.
 
Under Medicare rules, carriers will pay for a consultation if the requesting physician has not transferred the responsibility for a patient's care to the receiving physician. Medicare does not consider a patient under the care of a consulting physician simply because the patient's record is held by the physician group in which the consulting physician is employed.
 
The consulting physician does not have to code an office visit until he or she assumes responsibility for the patient's care. In that event, subsequent visits should be reported as an established patient office visit, 99211-99215.