Oncology & Hematology Coding Alert

Question: Our claims that include a diagnosis of family history consults are being denied. We have patients who are trying to decide what proactive treatments can be done, and the insurance companies are not paying for the consults or follow-ups. Is there a way to get paid for this type of service, and if so, what diagnosis codes should we use?

Michigan Subscriber

Answer: This issue is becoming increasingly important as genetic counseling and chemo-prevention become more prevalent. Unfortunately, many insurers do not cover preventive or screening services. Medicare, in particular, only covers items and services that are reasonable and necessary for the diagnosis or treatment of illness or injury or are needed to improve the functioning of a malformed body member Those definitions can be found in the Medicare Carriers Manual, section number 2303.

You may not bill Medicare patients for services considered not medically necessary unless you have a signed notice from the patient agreeing to pay. Insurers other than Medicare may provide some level of benefit for services such as those you describe. Each case should be treated individually and coverage verified with the payer before rendering service.

The patient then can be informed of coverage issues and make an educated decision about whether to pursue the service. If services are provided, care should be taken to code and document for the appropriate level of evaluation and management services (new patient visit, 99201-99205; consultation, 99241-99245; or follow-up visits, 99211-99215).

The appropriate diagnosis codes to use in the scenario you describe would be those under V16.x (family history of malignant neoplasm). Payer recognition of V codes is inconsistent and should be discussed with the payer when verifying coverage. Medicare coverage for V codes is carrier specific. Check with your local Medicare carrier about its coverage policy.

This question was answered by Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology, an oncology practice in Hooksett, N.J.