New Patient, Consultation, and Evaluation Codes

When the initial patient encounter is performed, this service is typically assigned either the new patient codes (99201-99205), or the office consultation codes (99241-99245). The new patient visit codes are assigned when the patient is referred to oncology for treatment, when the patient self-refers, or if the attending physician indicates: “evaluate and treat.” A consultation occurs when the attending physician requests that the patient be evaluated, and that the oncologist provide an opinion regarding patient treatment. The consultation requires documentation of the request for opinion or advice, a record of the patient encounter and a report containing the opinion or advice returned to the attending physician.

In addition to the patient visit fee, there may be situations where the oncologist also performs a minor surgical service such as a flexible fiberoptic laryngoscopy (CPT code 31575), flexible diagnostic sigmoidoscopy (CPT code 45330), nasopharyngoscopy (CPT code 92511), or other surgical procedure that would be considered for separate reimbursement.

It is essential that if reimbursement is requested for both the surgical procedure and the patient evaluation during the same encounter that documentation support the separate nature of the two services. If the surgical service is listed as part of patient examination, it is generally considered to be an integral part of the patient visit or consultation and not separately billed. If, however, there is a procedure note describing the surgical procedure that is distinct from the evaluation and management service (i.e., separate paragraph from the visit note), modifier –25 is appended to the visit code (significant, separately identifiable service) and the surgical procedure may be separately billed.

Last, remember that the separate surgical reimbursement applies both to the professional and facility portions of the procedure (there are APCs for most of these surgeries!).

Cindy C. Parman, CPC, CPC-H
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.  

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