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 [...]