Oncology & Hematology Coding Alert

Better safe than sorry, many hematology and oncology coders think. If you doubt that your physician's service qualifies as a consultation, you-re likely to code it as a lower-paying E/M code.

But you might be missing out on billing some consults because of misconceptions about what qualifies, says Stacie Buck, RHIA, CCS-P, LHRM, RCC, president of the Florida HIM Association. Here are some consult myths she exposed in The Coding Institute's recent audioconference "Surefire Strategies for E/M Reimbursement":

Reality: Medicare will accept consult requests from a doctor or nonphysician practitioner (NPP). And CPT rules allow a consult request from other sources, including attorneys, physical therapists, chiropractors, social workers or insurance companies.

Medicare won't cover a consult unless a doctor or NPP requests it. But don't assume that other payers will reject consults when the requests come from other sources, Buck says. Not all payers follow Medicare guidelines, and in those cases you should apply CPT guidelines, she adds.

Reality: CPT guidelines don't require a diagnosis to be unknown at the time of a consultation, Buck says. "The consultation could be for the purpose of assessing the best treatment option for the patient," she says. In this case, the requesting physician should note that he is seeking opinions or advice regarding treatment.

Reality: Nothing in CPT or Medicare guidelines forbids consult requests from doctors in the same practice or specialty, Buck says.

But Medicare expects consult requests within the same practice to be rare, she adds. For same-practice consults, the physician performing the consult should have expertise in a medical area beyond the requesting doctor's scope and expertise, she says.

CMS has clarified that a physician may provide a consultation for another physician of the same specialty, as long as you have documented all elements of the consultation service, and the consulting physician's knowledge and expertise goes above and beyond that of the requesting physician.

"It has to be clear that the physician in the group being asked for the consultation truly has a skill set that the requester does not have and that this is not being used just to get another consultation," says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders based in Salt Lake City. "I think practices have to use this with care and not too often. The reason and justification better be reflected in the chart."

Note: For more information, see "Clear up Same-Specialty MD Consult Rule" in vol. 9 no. 10 of Oncology Coding Alert.

Reality: There may be times when a physician provides a consult that consists only of counseling and coordination of care.

The referring physician may ask the consultant "to review patient records and offer advice on treatment options for the patient" without examining the patient, Buck says.

In this case, you should choose the consult level based on the amount of time the physician spends providing these services. The record should include total face-to-face time or floor/unit time, plus a summary of the counseling and care coordination, Buck says.

Note: For a CD or transcript of Buck's audioconference, go online to www.audioeducator.com/industry_conference.php?id=571.

The Medicare consultation guidelines are located at www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.