Oncology & Hematology Coding Alert

Although oncologists frequently provide consultations, properly reporting these E/M services remains a persistent coding challenge. Documentation is key, especially now that the HHS Office of Inspector General has listed consultations as one of the investigative focus areas of 2003.

As with E/M services, oncology coders should choose the level of consult codes according to the three elements of history, examination and medical decision-making. To bill consults, physicians must also meet other less clearly delineated important criteria including the ever-thorny documentation requirements, says Judy Murphy, CPC, NCICS, business office supervisor who specializes in radiation oncology with Northwest Cancer Specialists in Portland, Ore.

CPT 2003 includes four types of consultations: office or other outpatient (99241-99245), initial inpatient (99251-99255), follow-up inpatient (99261-99263), and confirmatory (99271-99275).

The first step to using the correct consultation code is identifying the location of the consult, choosing between an office or other outpatient setting (i.e., ER, ambulatory facility or rest home) and an inpatient setting (i.e., hospital, nursing facility or partial hospital setting), says Jennifer Darling, CORT, PA, billing and collections lead with the Center for Oncology Research and Treatment in Dallas.

Darling shares the case of a primary-care physician (PCP) who requests the opinion and advice of an oncologist for a 67-year-old female patient with enlarged lymph nodes (289.1, Chronic lymphadenitis). Following a complete evaluation, the oncologist treats the patient on the same day and does not recommend further therapy.

Because there has been an official request for the consultation, a documented reason for the consultation, and a written report sent to the attending physician, Darling notes that all criteria have been met for use of an office consultation code.

To code this service as an office consultation, you have to choose from the 99241-99245 series, depending on the level of the consult. "Most of our consults come from pulmonary or surgical doctors ob-gyns in particular," Murphy says. "Simply because of the diagnoses that we deal with, almost all of our consults are high-level."

The outpatient consultation codes do not have outlined restrictions on their frequency of use, and patients don't need to present with a new problem for an additional consultation code in the 99241-99245 range to be appropriate, according to the CPT 2003 guidelines.

"A lot of people don't realize that in a free-standing facility, the medical oncologists and the radiation oncologists consult with each other while doing concurrent care, in which a patient is receiving chemotherapy and radiation treatment at the same time," Murphy says.

There are many appropriate treatment sequences for cancer patients. Therefore, coders should get used to a barrage of inpatient and outpatient consult codes that will reflect several specialties initiating consultations at multiple points in the treatment sequence.

Keep in mind that both radiation oncology and ob-gyn procedures have 90-day global periods post-treatment, Murphy says. If the patient visit is not directly related to the previous procedure, then it may be billed as a consult. Otherwise, the visit falls within the global period. "We rely on a tickler system to keep track of office visits within that 90-day global period," she says.

For example, following surgery, a pulmonary patient begins to exhibit neurological deficits. Anew consultation with the radiation oncologist may show that the neurological deficits signal a new development requiring separate palliative care, Murphy says.

Typically, when a patient returns for an additional consultation after cancer treatment, the patient will have a problem that is either unrelated to or a progression of the original problem, says Jennifer C. Simpson, CPC, a practicing coder in Lexington, Ky. When these subsequent consultations take place, always be sure to include a detailed explanation for the additional consultation(s).

For example, a patient with an HIV diagnosis (079.53) might require several consultations with an oncologist for the progressive management of HIV-related anemia (284.8, Anemia due to chronic systemic disease). The subsequent visits to the oncologist may be considered another consultation, and if the service is provided in the office or outpatient facility, choose a code from the range 99241-99245.

Coders, take note: CPT does not provide follow-up codes for outpatient consultations, so you must use a code from the same range as the initial outpatient consultation code 99241-99245.

Additionally, outpatient consultation codes are not subdivided into new and established patient classifications, as are the office visit codes 99201-99215. Regardless of whether the patient is new or established, the definitions of these consult codes require that all three components of history, examination and medical decision-making be met before a consult level can be assigned. The doctor needn't gather the same history every visit, experts agree, but he must meet the required levels.

Satisfying all three components before assigning both new and established outpatient consultation levels also applies to inpatient consultations, Murphy says, but only the first consultation provided by a physician.

Note the CPT guidelines that instruct coders to use only one of the initial inpatient consultation codes, 99251-99255, per patient admission. Use the follow-up inpatient consultations for any subsequent consultations requested by the attending physician and provided during the same patient admission.

Use the follow-up codes, 99261-99263 when the physician who conducted an initial in-hospital consultation performs a second in-hospital consultation at the request of the consulting physician. The guidelines for these services indicate that two out of the three key components history, examination and medical decision-making are required to determine the level of consultation.

With terminal illnesses such as cancer, patients often exhibit problems requiring the skills of multiple specialists, Darling says.

For example, an oncologist who works in a private practice is called to the hospital to evaluate a patient with malignant secondary pleural effusion (197.2). The attending physician seeks the oncologist's advice on whether the patient has a condition in addition to diabetes. The oncologist bills an initial consult code and may then recommend consultations from other physicians. These other specialists also bill initial consultation codes for each of their first visits. After all the specialists see the patient, the oncologist performs a follow-up consult to determine his final diagnosis and to complete the requirements of the attending physician's original request.

Typically, "additional consults for other specialists should come from the attending who is managing the patient's care," Hickey notes. The diagnosis codes are then billed by the consulting physician with his consultation codes. The final and complete diagnosis list comes upon discharge from the attending. In this scenario, the final outcome is a primary diagnosis of ovarian cancer (183.0) from the oncologist, with supporting diagnoses of coronary artery disease (414.00) and hypercholesterolemia (272.0) contributed by a cardiologist and an endocrinologist.

In another twist, "if a patient is admitted to the hospital and has a consultation, and the patient is discharged from the hospital, readmitted and has a second consultation for the same problem as the previous consultation, you use the initial hospital consultation codes," says Kimberly Hodges, CPC, coding specialist for Guerrero & Salib, MDs, in Titusville, Fla. But if the patient has not been discharged from the hospital and requires a second consultation, even if it is for the same or a new problem, a follow-up consultation code is required regardless of the diagnosis.