Oncology & Hematology Coding Alert

Second opinions and confirmatory consults are not always synonymous. The same is true when it comes to coding for visits by patients seeking another opinion following a recent cancer diagnosis and proposed treatment plan.

When a patient presents for a second opinion, you have a number of E/M choices new patient, 99201-99205; office consultation, 99241-99245; and confirmatory consultation, 99271-99275.

What is performed in that visit will determine which code should be used, and oncology practices should not be quick to code the visit as a confirmatory consult simply because a second opinion is sought, says Dianna Hoffbeck, RN, CCM, ACFE, president of North Shore Medical, a billing, coding, collection and healthcare consulting firm in Atlantic City, N.J.

Also, practices that see a patient who schedules a visit on his or her own following a recent cancer diagnosis must remember that a referral from another physician is not a prerequisite for confirmatory consultation codes, says Nancy Giacomozzi, office manager for P.K. Administrative Services, a billing firm based in Englewood, Colo.

Consult or Second Opinion? Know the Difference

The purpose of a confirmatory consult is to obtain the specialists guidance and recommendations regarding the diagnosis, evaluation and/or treatment. Generally, this calls for a review of records and test results from the patients attending physician. According to Medicare regulations, confirmatory consultations may be provided in any setting. They consist of the services provided to patients history, exam and medical decision-making when the consulting doctor is aware of the confirmatory nature of the opinion sought. The physician is expected to provide an opinion or advice only.

Some other examples of when a confirmatory consultation would occur are when:

a patient initiates a second opinion;
an insurance company is paying for disability in questionable circumstances; and
an attorney requests review of a situation.

Second opinions occur under two circumstances:

1. With a consultation request from another oncologist. If the consult is requested by the patients attending physician, the procedures are similar to that of an office consultation a written or verbal request must be made to the consulting oncologist. The consulting physician must prepare a report. Another oncologist can request a confirmatory consult of a malignancy. Like an office consultation, the request must be documented as an order in the attending physicians note or in a signed consult sheet requesting information. A written report of the confirmatory consultation should be provided to the attending oncologist for inclusion in the medical record.

Coders must choose the appropriate code based on the three key components of an office visit (see chart in box below). This could include review of the patients medical record and the previous physicians findings. Further, the physician should provide the patient with his or her advice or opinion.

2. When the patient seeks a second opinion independently. If the consult is requested by the patient, the consulting oncologist should state that in his or her report. The fact that the patient was not referred to the oncologist by another physician does not preclude the practice from using confirmatory consultation codes, Giacomozzi says.

If the services provided in either case result in the physician assuming the patients care, any services subsequent to the opinion or advice should be coded using the appropriate established patient visit codes, 99211-99215, or subsequent hospital care codes, 99231-99233.

More than a confirmatory consult

Often, services provided as a result of a second opinion are far greater than a confirmatory consult.

The key to deciding whether to assign 99271-99275 or some other E/M code is to look at what services the physician provided, Hoffbeck recommends. Confirmatory consultations call for the consulting oncologist to provide only his or her opinion and advice.

But the consulting oncologist may provide more than this, including tests to confirm earlier findings. Coders should not be mislead by the term second opinion; the services should dictate the code assignment, rather than that term.

According to Hoffbeck, a former insurance case manager, it is entirely appropriate for an oncology physician to approach a second opinion from scratch, conducting the same type of exam and performing the same tests as one would to come up with an accurate diagnosis and effective treatment plan.

Savvy coders would see that although the visit was made to confirm a previous diagnosis, a new patient or consultation visit was performed, which is reimbursed at higher rates than consults. Codes 99241-99245 should be used when the visit was the result of a request for a consultation made by another physician.

Codes 99201-99205 should be used if the patient seeks the second opinion on his or her own. Although the visit was not the result of a referral or request for consult, confirmatory consult codes are allowed, but do not accurately reflect the services provided if the new physician provides more than his opinion and advice, such as administering a new battery of tests to come up with his own diagnosis.

Confirmatory Consultation Requirements Follow these guidelines for new or established patients: 99271: a problem focused history; a problem focused examination; and straightforward medical decision-making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs. Usually, the presenting problem(s) are self limited or minor. 99272: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision-making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs. Usually, the presenting problem(s) are of low severity. 99273: a detailed history; a detailed examination; and medical decision-making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs. Usually, the presenting problem(s) are of moderate severity. 99274: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs. Usually, the presenting problem(s) are of moderate to high severity. 99275: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs. Usually, the presenting problem(s) are of moderate to high severity.