Oncology & Hematology Coding Alert

Question: We-ve seen a lot of "self-referred" patients lately. Should I report these as consultations, or as new-patient E/M visits?

Iowa Subscriber

Answer: You should report these services as new-patient E/M visits (99201-99205).

Remember: You should report an established-patient visit (99211-99215) if a same-specialty physician in the practice has performed a face-to-face service for the patient in the past three years (according to the "Decision Tree for New vs. Established Patients" in the AMA's CPT 2008: Professional Edition).

You may consider radiation oncologists, medical oncologists and hematologists separate specialties. Therefore, if a radiation oncologist saw a patient a year ago, and the patient now presents to a medical oncologist, you should report a new-patient code for the medical oncologist visit.

But, if a radiation oncologist who specializes in lung cancer sees or treats the patient originally, and the patient returns within six months for treatment by the radiation oncologist who specializes in brain metastases, both physicians are of the same specialty. You would therefore report an established-patient visit.

Avoid consult code: You should not report a consult service (99241-99245) for a self-referred patient because another provider did not request an opinion or advice.

Remember: For Medicare patients, if you suspect your carrier won't cover the service, have the patient sign an Advance Beneficiary Notice (ABN) alerting him that he may have to pay the charges.

On the other hand, if the patient comes to you because the insurer required the visit, append modifier 32 (Mandated services) to the E/M code.