Daily Practice

Evaluation and Management

Coding Question: Do Medicare or Medicaid require that a patient receive a referral from another physician in order for the patient to see a radiation oncologist? If so, what should one do if the patient self-refers himself/herself to you because of reputation/friend etc.?  How would the radiation oncologist bill for the initial evaluation and management consult?

Coding Answer: No, Medicare and Medicaid do not require that a new patient be referred by another physician.  The CMS definition states that for a patient to be regarded as a new patient, the patient must not have “received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the last three years.” Therefore, any patient presenting him/herself to you would be regarded as a new patient.
The office and other outpatient visit codes for new patients (CPT 99201- 99205) are recognized for reimbursement by CMS and may be used to report any new patient being seen in your practice. There is no distinction between a patient who is referred by a physician or one who is self-referred; for Medicare they are both considered a new patient.

Coding Question: If a radiation oncologist provides E/M services to his/her patients via telephone, can they bill 99441, 99442 and/or 99443? Also, can a Medicare Provider bill these CPT codes and, if so, where can the pricing be found on the Medicare Fee Schedule? Can this kind of phone service be billed under any other E/M billing code that is on the Medicare Fee Schedule?

Coding Answer: CPT codes 99441 - 99443 describe telephone evaluation and management services provided by a physician to an established patient. The patient or patient’s parent/guardian must initiate the contact as these codes may not be used for calls initiated by a provider. The codes are differentiated according to the length of the medical discussion with the patient. These codes are used only for services personally performed by a physician. CPT codes 98966-98968 describe telephone services performed by qualified non-physician health care professionals. Medicare has designated all telephone evaluation management codes with a status indicator “N” which indicates the service is not covered by Medicare, and thus the pricing information will not be found on the Medicare Fee schedule. It should be noted that relative value units (RVUs) are listed for these codes in the Medicare Physician Fee Schedule. Therefore, while Medicare does not cover these services, some private payers could potentially cover these services and use the RVUs assigned by Medicare to set payment rates. ASTRO recommends you review the current policies of your major payers to determine their coverage policies regarding telephone evaluation management services. Phone calls during treatment are included in the work captured in CPT code 77427, which includes a 90-day global period after treatment is completed, and therefore CPT codes 99441 – 99443 cannot be billed separately during this time.

Disclaimer: The opinions referenced are those of members of the ASTRO Code Utilization and Application Subcommittee based on their coding experience and they are provided, without charge, as a service to the profession. They are based on the commonly used codes in radiation oncology, which are not all inclusive. Always check with your local insurance carriers, as policies vary by region. The final decision for coding for any procedure must be made by the physician, considering regulations of insurance carriers and any local, state or federal laws that apply to the physicians practice. ASTRO nor any of its officers, directors, agents, employees, committee members or other representatives shall have any liability for any claim, whether founded or unfounded, of any kind whatsoever, including but not limited to any claim for costs and legal fees, arising from the use of these opinions.  

All CPT code descriptors have been taken from Current Procedural Terminology (CPT®) 2015, American Medical Association. All Rights Reserved.

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