Oncology & Hematology Coding Alert

From time to time there is uncertainty over whether a patient encounter is a consult or an office visit. In the case of a physician seeking the consult of another physician in the same group, some billers are reluctant to code for a consult. They are concerned that payers would consider the patientfor billing purposesin the care of the entire physician group.

As long as the consulting physician in the same group meets the requirements of a consult, he or she can bill for a consult, says Elaine Towle, CMPE, practice administrator for the New Hampshire Oncology-Hematology in Hooksett, NH. A consultation is eligible for payment when all of the criteria for the use of a consultation code are met, regardless of whether referring and consulting physician are members of the same practice, says Towle. She adds that the medical record should identify the problem that requires the need for a consult; it should support the level of consultation code by describing the extent of history, exam and medical decision-making required; it should include the consultants findings.

Under Medicare rules, carriers will pay for a consultation if the referring physician has not transferred the responsibility for a patients care to the receiving physician. Medicare does not consider a patient under the care of a consulting physician simply because the patients record is held by the physician group in which the consulting physician is employed.

For example, an oncologist in a multispecialty group practice can safely bill for a consult if a primary-care physician (PCP) within the group seeks the oncology physicians medical expertise. After the consulting physician assumes responsibility for the patients care that subsequent visits should be reported as an established patient office visit. For example, established patient visit codes should be used if the consulting physician finds a tumor in a female patients breast, recommends a course of treatment and the referring physician transfers responsibility for carrying out the new treatment plan to the consulting physician.

When a PCP in a multispecialty practice seeks the consult of an oncologist within the same practice, the use of a consult code is cut and dry. There is no question that the PCP is seeking expertise outside his or her own expertise.

But when an oncologist seeks a consult with another oncologist within the same group can be a bit more tricky, says Rebecca Dawson, CPC, a compliance education specialist for an academic medical center in Ohio. You have to prove necessity. For example, you need to show that the consulting oncologist has a subspecialty.

To prove medical necessity in this situation, the physician can refer back to the consultation guidelines: The medical record should show the problem that is necessitating the consult. In addition, Dawson says that the consulting physician within the same group should possess credentials that show the expertise the attending physician is seeking.

In general, a consultation is distinguished from a regular patient visit because a referring physician requested it. In addition, the consultant prepares a report of his or her findings, which is provided to the referring physician for use in treating the patient. The requirements are the same for consultants within an attending physicians group practice and those outside the group. The consulting physician can bill for a consult provided history and exam are performed, extent of medical decision-making is documented and written report of the consultants findings are given to the attending physician.

Physicians providing second and third opinions also are eligible to use consultation codes, Towle says. A second opinion requested by a patient is a common occurrence, and on rare occasions the patient will seek the advice of a physician within the same group as his or her attending physician. For example, a female patient who is diagnosed with uterine cancer and faces a hysterectomy may seek the opinion of another oncologist in the group.

Medicare will cover the work of a second physician who comes in as a consultant at the patients request if the patient faces surgery or a major procedure. If the second opinion differs from the original opinion, Medicare will pay for a third opinion.

How to Define a Consultation There are five levels of office consultation services, each with a unique set of requirements. 99241 (level 1 office consultation) requires a problem-focused history, a problem-focused examination, and straightforward decision making. In comparison, 99245 (level 5 office consultation) requires a comprehensive history, a comprehensive examination, and medical decision making of high complexity. The general criteria for a consultation are as follows: The patients physician must make a written or verbal request; that is, consultations must be physician initiated. A physician service initiated by a patient and/or family, and not requested in writing or verbally from the attending physician directly to the consulting physician, may not be reported using the initial consultation codes but may be reported using the codes for confirmatory consultation or office visit code. The patient record must prove medical necessity for a consult. In most cases an abnormality that has the potential for a cancer diagnosis is sufficient. All tests and services performed must be documented in the patients medical record. A written report must communicate the tests and services and the consulting physicians findings to the referring physician.