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Oncology & Hematology Coding Alert

Reader Question:

Consult or New Patient?

Published on Mon Jul 01, 2002

Question: Should I bill a patient's first office visit with an oncologist as a consult or new patient office visit?

Ohio Subscriber

Answer: Oncology practices must follow specific guidelines before billing the patient's first visit as a consult (99241-99245) rather than a new patient office visit (99201-99205). This is an important distinction because payments for consults are much higher than the other evaluation and management (E/M) services. However, if you consistently code an office visit as a consultation, you are at risk for Medicare fraud and abuse charges.

Keep the following four criteria in mind to ensure that visits coded as consultations meet Medicare and CPT guidelines:

  • The treating physician must have made a formal request for a consultation, and this request should be documented by both physicians

  • The request for the patient visit requires the oncologist to render a medical opinion

  • The consulting oncologist must provide a written report of the findings and send this report to the referring physician

  • The consultation does not involve ongoing, active management of the patient problem. However, diagnostic and/or therapeutic services may be initiated.

    Conversely, the following factors do not support the assignment of a consultation code:

  • Standing orders in the medical record do not constitute a consultation

  • No direct request for a consultation has been received

  • The oncologist has not provided a written report back to the requesting physician

  • A patient-generated request for a confirmatory consultation does not qualify as a consultation.

    You should also ensure that no transfer of care from the referring physician to the oncologist occurred. This occurs when the full responsibility of the patient's complete care is taken over by the receiving physician at the time of referral. In this case, the physician should bill for a new patient visit (99201-99205) or an established patient visit (99211-99215).

    Reader Questions and You Be the Coder were answered and reviewed by Margaret Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant based in New Orleans; Cindy Parman, CPC, CPC-H, president and co-founder of Coding Strategies in Atlanta; and Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett.

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