Oncology & Hematology Coding Alert

You can still report a consult if your physician begins treatment Coders across all specialties consistently struggle with consultation coding rules, but if you can identify the three characteristics that distinguish a consult from other E/M services, you-re well on your way to trouble-free claims. Learn It by Heart: Request, Reason, and Report Before reporting a consultation service (99241-99255), you must be sure that documentation of the visit provides evidence of all of the following: 1. A request for consultation. This is a note from another physician asking your oncologist or hematologist to evaluate the patient. Get it in writing: A verbal request for consultation is not sufficient. CMS regulations (Medicare Claims Processing Manual, chapter 12, section 30.6.10) specify, "The initial request may be a verbal interaction between the requesting physician and the consulting physician; however, the verbal conversation shall be documented in the patient's medical record." Important: Patients can never "self-request" a consultation. The consult request must come from another physician or "other appropriate source," according to CMS rules. Payers do not consistently agree on what qualifies as an "other appropriate source" for a consultation request. If you receive a consultation request from a nonphysician, such as a nurse practitioner, talk to your payer before coding the claim. 2. A reason for the consultation. The requesting physician must specify why he is asking your oncologist to evaluate the patient. Medicare Claims Processing Manual guidelines stress, "The reason for the consultation service shall be doc-umented by the consultant in the patient's medical record and included in the requesting physician's plan of care." 3. A report from the consulting physician, outlining his findings and recommendations, to the requesting physician. Once again, the Medicare Claims Processing Manual explicitly states, "After the consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician." Meet the documentation requirements: In most outpatient settings, the consult request is a separate document sent from one physician to another, as is the report. In the inpatient setting, however, the request, reason, and report may be part of the shared medical record. Exception to the rule: In the emergency department or other outpatient setting in which the medical record is shared between the requesting and consulting physicians, the request, reason, and report may also be a part of the shared record. Ask Yourself, -What's the Point?- Even when you have a documented request, reason, and report (and you must have all of these before you even consider a consultation code), whether you should claim a consultation rather than an appropriate inpatient or outpatient E/M service depends on an honest answer to the question, "What was the purpose [...]