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.
Proving Medical Necessity  
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 [...]