Urology Coding Alert

Hint: If you can't prove the request for an opinion, don't use 99251-99255.

When another physician calls your urologist into the operating room, do you automatically assign a consultation code to that service? If so, now's the time to stop.

In Urology Coding Alert Vol. 11, No. 9, you read the answers to the top three consultation coding questions. If your urologist frequently gets called into the OR by other surgeons, you may still have some lingering questions.

Here's what you need to know about intra-operative consultation services.

Determine What Warrants an Intra-Operative Consult

Another surgeon may request an intra-operative consultation from your urologist to evaluate an unexpected urological problem or complication that occurred during his surgery. This visit must still meet all the requirements of a consultation, says Tina Landskroener, CPC, CCS-P, PCS, business office manager for Blessing Physician Services in Quincy, Ill. Keep in mind that the request should not simply be for a routine screening.

Example: Your urologist was called to the operating room to perform corrective surgery, such as the repair of an accidental injury to the bladder during pelvic surgery. There was no real request for an opinion or recommendation as the problem was obvious, and the urologist was called only to do the repair. In this case, there is no consultation, and you should not bill a consultation. But keep in mind that a consultation may lead to treatment once the physician completes his consultation.

Identify the Request for Opinion

"You would bill a consult only if the primary doctor requested of your doctor an opinion and/or recommendation on a specific condition," confirms Tracy Helget, CPC, billing office supervisor for Medical Associates of  Manhattan PA in Kansas.

If another physician requested that your doctor perform only a surgery, and there was no request for an  opinion or recommendation, then there would be no consultation. "It all depends on how services are documented," Helget says.

In other words, you would bill a consult only if the surgeon had requested an intra-operative urological opinion and/or recommendation as to whether a bladder injury in fact had occurred, and whether corrective surgery would be needed. If the surgeon asked your urologist to perform surgery for an obvious injury, and there was no need for an opinion, you would not bill a consultation.

Note: A separate report sent to the requesting physician is not required when the requesting physician and consultant share a common medical record (which always occurs in the inpatient setting).

Add 57 or 25 For Same-Day Procedures

If the service does qualify for a consultation code, bill  an inpatient consultation using the most appropriate choice from 99251-99255 (Inpatient consultation for a new or established patient ...), depending on the level of service and documentation in the common medical record. Most often, because of the clinical circumstances, you will report an intraoperative consultation as a level-two service: 99252.

Remember: If the urologist's consultation leads to a same-day surgical procedure to correct a problem, you need a modifier. Add modifier 57 (Decision for surgery) to the consultation code for a major surgical procedure, or modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the consultation code for minor surgery, says Samantha Daily, medical biller for Urologic Consultants PC in Portland, Ore.

You need to append the modifier to give the payer additional information, Daily says. "If a provider reviews the patient's family and social histories and does a minor exam, then the provider should get credit for that. Those areas contribute overall to the medical decision making, which does tend to be straightforward, unless there's a complication," she adds.

Tip: If you're reporting a consultation code out of the operating room but in the hospital or in an emergency room (ER), you should also make sure that the referring physician has his own National Provider Identifier (NPI).

"Not all ER physicians or hospitalists have their own," Daily warns. This will cause payment issues on your end when you report a consultation code with no referring physician NPI on the claim form.