Oncology & Hematology Coding Alert

Beware that Medicare recognition remains to be seen.

Among the changes set to take effect to the evaluation and management (E/M) guidelines next year, you’ll see revisions to the inpatient consultation codes (99252-99255, Inpatient or observation consultation for a new or established patient …) and office/outpatient consultation codes (99242-99245, Office or other outpatient consultation …).

Currently, to determine service levels for these codes, you have been applying the 1995/1997 documentation guidelines, using history, exam, and/or medical decision making (MDM) or time, when appropriate, by applying the 50 percent counselling and/or coordination of care guideline.

Equivalent to the changes made to the initial and subsequent inpatient/observation care and same-day admission and discharge E/M services (99221-99223, 99231-99233, and 99234-99236), you’ll now have the option to code the office/outpatient consultation codes based on MDM or total physician/other qualified healthcare professional time on the date of the encounter, whichever is more advantageous to the provider.

Here, then, are all the changes to 99242-99245 that you need to know prior to using the codes on Jan. 1, 2023.

Apply 2021 E/M Rules to Consultations Next Year

To begin with, CPT^® has changed the wording in the consultations guidelines to allow “other qualified healthcare professionals” to perform E/M consultations in addition to starting diagnostic or therapeutic services during the visit or at a subsequent visit.

Additionally, CPT^® has revised the places of service (POS), allowing you to use 99242-99245 to “… report consultations that are provided in the office or other outpatient site, including the home or residence, or emergency department,” in 2023. While use of these codes for the above listed places of service is not new, hospital consultation services will now require a different set of E/M codes due to the code revision combining inpatient and observation and consultation services. These services will now use 99252-99255 instead of 99242-99245 as they have in the past.

Mandatory modifier: The guidelines also state that you should append modifier 32 (Mandated services) to a required consultation. For example, if a payer requests a consultation, such as a second opinion before the payer approves treatment, you should append modifier 32 to the applicable consultation code.

Review These Office Consultation Code Revisions

Key code deletion: In keeping with the level one office/outpatient E/M code deletions of 2021, CPT^® has deleted the lowest level office (99241) outpatient consultation codes to align with the four levels of MDM in 2023. Beginning Jan. 1, you’ll report 99242 for an outpatient consultation that involves straightforward MDM.

The updated office/outpatient consultation E/M codes will allow providers to select the level of service based on MDM or time. Here’s what they will look like in 2023, with portions of the revised descriptors emphasized for easy reference:

• 99242 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straight­forward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.)
• 99243 (… low level of medical decision making … 30 minutes must be met or exceeded.)
• 99244 (… moderate level of medical decision making … 40 minutes must be met or exceeded.)
• 99245 (… high level of medical decision making … 55 minutes must be met or exceeded.)

Notably, references to the required level of history and examination are deleted and substituted with “a medically appropriate history and/or exam,” which are the same changes made in 2021 to the descriptors for the office/outpatient E/M codes.

Coding for prolonged services: CPT^® adds a parenthetical note after 99245, instructing you to use add-on code +99417 (Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure…) for services lasting 70 minutes or longer. Accordingly, the new descriptor revises the language that previously said you should only use +99417 in conjunction with 99205/99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …). Instead, you will now be able to use +99417 with any of the highest-level E/M services that can be billed by total time if your payer accepts prolonged service billing using CPT^® guidelines.

Remember: CPT^® instructs you to add one unit of the code when time documented hits 15 minutes beyond the minimum E/M time ranges for the date of service with and without direct patient contact. Time spent on separately reportable services is not counted. For 99245, that means you would apply +99417 after the initial 55 minutes of the consultation — in other words, when total time reaches 70 minutes. However, CMS argues that prolonged service time should be reported when the total time for visits hit 15 minutes beyond the maximum time range. Consequently, in 2021, Medicare introduced a separate prolonged services code — G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure …) — for the 99205/99215 time ranges. “Unless changes are implemented, G2212 would be the appropriate code to represent prolonged service time for a Medicare patient when the maximum time has been exceeded by 15 minutes,” says Leah Fuller, CPC, COC, with Pinnacle Enterprise Risk Consulting Services in Charlotte, NC.

Follow These Pro Tips on Coding Consultations in 2023

“As this range of consultation codes can be documented through either time or MDM … history and exam, as with office visits, are no longer key components of consultations,” says Nancy Clark, CPC, COC, CPB, CPMA, CPC-I, COPC, AAPC Fellow, senior manager at Eisner Advisory Group LLC in Iselin, New Jersey.

Instead, you’ll use either documented physician/other qualified healthcare professional time or MDM to support your E/M consultation code choice. So, if you have a report stating the provider reached a certain level of MDM, but the total time surpassed what’s assigned to the code for that level of MDM, you can “select the method that benefits the provider,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia. In other words, “if the provider believes the encounter was especially lengthy, they may choose to document the time spent in various activities and select a code based on time,” Clark adds.

Take note: Documentation in the medical record should indicate how the time was spent — reviewing incoming records, obtaining a detailed history, performing an exam, education and discussion with patient and family, discussing patient status with another provider on the care team, and so on. A cryptic note, such as the patient was in the office for 55 minutes, would likely be challenged in a payer audit.

Will Medicare Now Recognize Consultation Codes?

As you probably already know, Medicare Part B and some private payers have not been paying for the current consultation codes. This means, whenever you have been asked for a consult from another physician to evaluate a Medicare patient, you’ve been using the office visit codes (99202-99215) instead of the consult codes.

Whether Medicare will revisit this policy in light of the code changes remains to be seen. But Oncology & Hematology Coding Alert will be monitoring the situation and will keep you informed.

For the full list of 2023 E/M code and guideline revisions, go to www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf.