Oncology & Hematology Coding Alert

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.

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.

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 of the visit?" says Barbara Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, senior coder and auditor for The Coding Network, and past member of the AAPC National Advisory Board.

"Essentially, the oncologist/hematologist can report a consultation when they are educating the attending physician on how to continue to treat the patient. If it is the intent of the attending physician to have the receiving physician recommend treatment options to the patient, then it is not a consult," says Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and past president of the American Academy of Professional Coders National Advisory Board.

A consult begins with an attending physician saying, in effect, "I have a patient with this set of signs and symptoms that I do not have the expertise to evaluate. I-d like you [the consultant] to diagnose the problem and advise me on how to treat it. I-ll take if from there."

The consulting physician then replies, "Here's what I-ve found, and here's my advice on how you [the attending/requesting physician] can best continue to treat the patient."

A consulting physician may perform diagnostic testing as part of a consultation service, or may even take over care of the patient at a later date (see sidebar, page 93), but the point of a consultation is always the same: With the consulting physician's advice as a guide, the attending/ requesting physician intends to continue to treat the patient.

"The report back to the requesting physician is not a -thank you- for referring the patient, and it is not a courtesy copy of the history and physical. It is education and instructions that will allow the attending physician to continue treating the patient," Parman stresses.

If the attending physician always intends for the "consultant" to take over the patient's care, you cannot report a consult service. Instead, this service represents a "transfer of care," for which you would report an appropriate inpatient or outpatient E/M service code.

"If the patient is -referred- from the surgeon for the oncologist to discuss treatment options, there is no expectation on the part of the surgeon that he will provide additional treatment," Parman continues.

Example 1: A surgeon plans invasive surgery for a patient who has previously received radiation treatment to the same anatomic area. The surgeon asks the radiation oncologist to evaluate the patient to determine if there are any special concerns relating to the proposed surgery (such as adhesions or altered internal architecture). The radiation oncologist examines the patient, details the risks from his viewpoint and advises the surgeon that the patient should be able to tolerate the surgical procedure without major ill effects. In addition, the oncologist recommends that the surgeon consult with a pulmonologist to ensure that the patient's lung function will allow for general anesthesia.

In this case, all the elements of a consultation are in evidence. There is a request, a reason, and a report, and the requesting surgeon always intended to continue to treat the patient. You would report an appropriate level outpatient consultation 99241-99245 for this service.

Example 2: A dermatologist suspects that a patient with malignant melanoma of the thigh (172.7, Malignant melanoma of skin; lower limb, including hip) might benefit from chemotherapy. The dermatologist suggests that the patient receive an evaluation from your medical oncologist. Your oncologist evaluates the patient and decides that the patient would not benefit from chemotherapy at this time.

This is not a consult -- even if, for instance, the oncologist prepares a written report explaining his findings and treatment recommendations for the dermatologist.

Here's why: There is no expectation that the dermatologist will continue treatment if the patient requires chemotherapy.

This is a referral rather than a consultation, Cobuzzi stresses. You would report an appropriate new patient E/M visit (99201-99205) for this service.

True consultations are relatively infrequent in oncology and hematology practice. Most often, physicians will refer a patient to an oncologist or hematologist with the understanding that the oncologist or hematologist will take over the patient's care from the outset.

Nevertheless, you do want to identify and report consultations when they happen.

Why it matters: Consultation services reimburse at a higher rate than the equivalent outpatient or inpatient E/M codes (99201-99215 and 99231-99233). For example, a level three outpatient consultation (99243) pays 1.88 physician work relative value units, while a level three new outpatient E/M service (99213) reimburses less than half that amount (.92 RVUs).