Oncology Coding Article-Consultation or Not?


Is The New Patient Visit a “Consultation” or Not?

Is the new patient visit a “consultation” or not? According to the definition of a consultation (CPT codes 99241-99245 and 99251-99255), one physician must request opinion or advice from another physician. If the patient self-refers, if the attending physician tells the patient to call the oncologist for an appointment, or if the attending physician sends the patient to “evaluate and treat”, it is probably not a consultation. In this situation, the patient encounter would be considered a new patient visit (CPT codes 99201-99205).

While consultations pay slightly more than new patient visits, Medicare clearly states that a consultation must include documentation of the request for opinion or advice in the patient medical record. At present, this documentation may take any form: written notice of telephone call from the other physician, written request for a consultation, email request (printed for the record), etc. In addition, the consultation service must be documented as evaluation of the patient with the provision of an opinion to the attending physician, and a copy of the written report providing the opinion or advice must also be included in the medical record. A courtesy copy of the history and physical may not be enough to substantiate the provision of opinion or advice in the event of an audit!

Verbiage should clearly reflect a consultation when this service is rendered. For example: “The patient is examined today at the request of her family practice physician to determine if treatment offered by our oncology practice will benefit her overall treatment plan.” Last, the Office of the Inspector General (OIG) has included investigation of consultation charges on its 2003 Work Plan, so all government insurers will be looking closely at these services.

Cindy C. Parman, CPC, CPC-Hcparman-5472038
principal and co-founder of Coding Strategies, Inc. in Atlanta, GA. Cindy is a current member of the Advisory Board for the American Academy of Professional Coders (AAPC) and a faculty instructor for AMA Solutions, a subsidiary of the American Medical Association.  She serves as the Consulting Editor of the Radiology Coding Alert and is on the Editorial Advisory Board of General Surgery Coding Alert and Pain Management Coding Alert.