# Vasectomy Consults/New patient-E/M level?



## wahrens1 (Jul 30, 2014)

What e/m level are most coders billing for Vasectomy new patients in clinic?  A couple of my urology providers think a level 3 or 4 new patient is customarily billed in private practice?  Usually there is very limited HPI for this type of discussion, so it is difficult to meet higher than a 2 in my opinion, unless billing based on time?  What are most coders billing?  Thanks


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## nateich (Jul 30, 2014)

I agree with you. We were lacking in the HPI captured by the physician. After, reading the below, written by Dr. Ray Painter in October 2010 we modified the way we were capturing the HPI portion. Our physicians typically perform a Comprehensive Exam and Moderate MDM is always met. A majority of these cases are at level 3 but thru education we are seeing an improvement in documentation. Hope this helps.

"You cannot capture a high-level history on a vasectomy patient because you cannot capture four bullet points on the History of Present Illness." A third-, fourth-, and fifth-level new patient or consult code requires four of the eight bullet points for a history of present illness. If you are willing to think outside the box on such issues as fertility and infertility, you can capture at least four elements on the history. For example, location is always a given, duration can be addressed by stating time frames for considering a change in fertility, there are usually associated signs and symptoms such as the ability to have intercourse and an erection, and certainly modifying factors—and at times contexts—can be captured as well, such as number of children and ages of children.


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## wahrens1 (Jul 31, 2014)

Thanks for the great info Natalie.  Can I ask what bumps this to moderate medical decision making just for my own understanding?  I was thinking minor surgery w/o risk factors?  Although I know there is an increased risk of prostate cancer, according to one of my urologists.  So is that what bumps it to a moderate level?  Do you give a 3 to all new patient's even if there isn't a new "problem" or "illness" or injury to investigate, no labs or xrays?  Is ferility considered a problem?  I'm just thinking outloud and I appreciate your thoughts.  Could you elaborate on how to get to that moderate level?  That would really help me.


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## nateich (Jul 31, 2014)

Here's my thoughts, there is a 90 global with a vas; Medicare considers those surgeries with 90 days a "major" surgery. There is always a risk of infection, failure for sterility, chronic testicular pain. On the Table of Risk this = Moderate.

I think of Minor w/o risk as a biopsy or removal of skin lesion.

I consider the Number of Diagnosis/Treatment Options to be New Problem, requiring additional work up ie vasectomy = 4.

Fertility is a "problem" since the patient does not want to have more children and is seeking medical intervention.

The MDM requires only 2 of 3, therefore Type of Data does not need to be completed/captured.

Again, the above is what our practice follows with the appropriate documentation. 

Hope this helps clarify.


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## wahrens1 (Jul 31, 2014)

Yes, it does.  Thanks for your help!


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## acjz28 (Jul 26, 2019)

nateich said:


> Here's my thoughts, there is a 90 global with a vas; Medicare considers those surgeries with 90 days a "major" surgery. There is always a risk of infection, failure for sterility, chronic testicular pain. On the Table of Risk this = Moderate.
> 
> I think of Minor w/o risk as a biopsy or removal of skin lesion.
> 
> ...


on a new patient you still need 3 or 3 met. So you still need 4 hpi. Established is only 2 of 3 which MDM and Exam would be ok but she stated this is a new  patient. So your advise is to have the doctor talk about infertility since they will no longer be able to produce?


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