Oncology & Hematology Coding Alert

Question: A local oncologist (not in our practice) recommended IMRT for his patient. But before the patient's insurer would approve the treatment, the payer asked our physician to conduct a physical examination of the patient.

We-d like to report 99243 for this service, but that's what the first oncologist reported. Will the insurer reject our claim as double-billing?


Arizona Subscriber 


Answer: The insurer might reject your claim for the consult, unless you append modifier 32 (Mandated services) to 99243 (Office consultation for a new or established patient ...).

Modifier 32 signals the carrier that the payer requested the consult and that the service is therefore not a redundant claim. The modifier generally describes procedures or services required by a third-party payer or a governmental or legislative agency.

Note: Medicare doesn't reimburse for second- opinion exams you report with modifier 32 because another insurance company requires the exam. The insurer requesting the second opinion should make payment under the terms of its policy.