Part B Insider (Multispecialty) Coding Alert

Published on Sun Jun 11, 2006 PDF

Bad news:  Using a nonphysician practitioner could cut reimbursement by 15 percent

Caring for melanoma patients always involves a consult, but coding for the consult can be tricky when two or more physicians are working together on one case.

Dermatologists and surgical oncologists often treat melanoma patients, but other physicians may send patients to your medical or radiation oncologist for a consult to determine whether the patient needs further treatment.

ICD-9 note: Oncologists usually see patients for consults after they have a positive pathology, says Elaine Towle, CMPE, program director for Oncology Metrics in Ft. Worth, TX. That means the documentation should reveal a confirmed diagnosis.

Example #1: A patient with a confirmed diagnosis of malignant melanoma of the back arrives for a consult. The neoplasm table entry for "Melanoma" is "See Melanoma." You look up "Melanoma" in the alphabetic index, which indicates 172.5 for back melanoma. You check the tabular index and determine 172.5 (Malignant melanoma of skin; trunk, except scrotum) is the correct code for your claim.
To count on consult reimbursement, you must make sure the requesting physician's original consultation request specifies why the patient needs the service, according to MLN Matters article MM4215. And be sure that the original request is in the patient's medical record.

Likewise, the consulting physician--the oncologist--needs to document this reason. Then, the oncologist must document both the exam and the opinion he renders, and he must send a report of his findings and opinion back to the requesting physician.

Example #2: A dermatologist suspects that his patient who has malignant melanoma of the thigh (172.7, Malignant melanoma of skin; lower limb, including hip) might benefit from chemotherapy. While the patient is admitted to the hospital, the dermatologist requests an evaluation from a medical oncologist. In the consult request, the dermatologist documents his reason and records the request in the patient's medical record.

The oncologist performs a level-three consult (99253, Initial inpatient consultation...) and decides the patient would not benefit from chemotherapy at this time. The oncologist documents the reason for the dermatologist's request and any advice he renders, and then he reports this to the dermatologist with a note to continue monitoring the patient.

Pitfall: If your oncologist sends his nonphysician practitioner (NPP) to take care of the preliminary workup for an inpatient consultation, he could be cutting out 15 percent of his usual reimbursement. You'll have to code the service under the NPP's name and number for Medicare patients.