Urology Coding Alert

 We've examined your queries, now we tackle the solutions

If you're still trying to get a handle on the consultation coding guidelines, let us help you get on the right track. We've gathered your top-five consult coding questions and put our experts to the test. Review the following questions and answers to get the lowdown on everything from preoperative clearances to second opinions.
 
1. Don't Stress About Consult Frequency

Question: How often can we report consult codes for the same patient? We saw a patient in September for a consult, and then the urologist saw her again for another consultation in March. Can we bill both consults?

Answer: The outpatient consultation codes (99241-99245) do not have outlined restrictions on their frequency of use, and it is not necessary for the patient to present with a new problem for an additional consultation code to be appropriate. According to CPT 2006, "If an additional request for an opinion or advice regarding the same or a new problem is received from the attending physician and documented in the medical record, the office consultation codes may be used again."
 
Typically, when a patient returns for an additional consultation, he has a problem unrelated to the original complaint or has a progression of the original problem. If the urologist performs an additional consultation for a given patient, be sure the documentation includes a detailed explanation for the subsequent consultation(s).
 
For example: Suppose a 70-year-old male patient is sent by his primary-care physician (PCP) to a urologist for his opinion and advice concerning a slightly elevated prostate-specific antigen (PSA) level. Following a complete evaluation, no further therapy is recommended and the urologist returns the patient to the PCP for follow-up care.
 
One year later, the PCP performs a repeat PSA that indicates a markedly increased level. The PCP requests another opinion from the same urologist on further management. This second visit to the urologist is considered another consult, and if the service is provided in the office or outpatient facility, choose a code from the range 99241-99245.

Meet the Consult Requirements

Important: You can collect for a consultation on an established patient if you meet the consult requirements. For example, suppose the urologist sees an established 65-year-old male patient in follow-up for an enlarged prostate gland (600.00) on Monday morning. The urologist examines the patient and renews his medication, warranting office visit code 99213. Later that same week, the patient visits his internist complaining of flank pain. Uncertain of the diagnosis, the internist requests an opinion from the patient's urologist.
 
This second visit to the urologist satisfies the criteria for a consultation and merits a code from range 99241-99245. In this case, the diagnosis is renal colic, 788.0.
 
Note that the new consult guidelines do not allow you to report an inpatient consult more than once during a given patient's stay.

2. Does a Letter Mean You Performed a Consult?

Question: We often get letters from other physicians that state, "I am referring this patient to you for treatment of a kidney stone ..." or other problem. Our physician performs a consult and sends a letter to the referring physician and insists that we bill a consult for this. It sounds like a transfer of care. Can we report the consult codes?

Answer: A letter from the urologist to the PCP, although informative, does not necessarily constitute   or change an encounter to a consultation. Whether the visit is a consultation depends on the services the urologist performs.
 
Tip: Be careful you're not writing a report just so you can bill a consult code. "For a visit to be billed as a consultation, everyone's documentation has to match," says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky.
 
The PCP must state that he is seeking the urologist's advice and opinion, and the urologist's documentation must indicate that he reviewed the patient at the PCP's request and sent a report to the PCP with his findings. The letter alone won't hold up your consult claim if an auditor reviews your files.

Identify a Transfer of Care

What constitutes a transfer of care? According to CMS Transmittal 788, "A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patient's complete care for the condition and does not expect to continue treating or caring for the patient for that condition. When this transfer is arranged, the requesting physician or qualified NPP is not asking for an opinion or advice on how to personally treat this patient and is not expecting to continue treating the patient for the condition."
 
If the referring physician sends you a letter that indicates he wants you to treat a kidney stone, he does not want or need your urologist's opinion or advice. Instead, he seems to be asking your urologist to take over and treat the kidney stone. Therefore, you should report a code from the 99201-99205 new patient series for the encounter, not a consult code.

3. Watch Out for Pre-Vasectomy Consults

Question: A PCP referred a patient to our practice because the patient wanted to get more information about a vasectomy. Our urologist billed it as a consult, arguing that the PCP referred the patient, the urologist consulted with the patient, and the urologist sent a letter to the PCP. Is  this correct?

Answer: Frequently, a patient, at the request of his PCP, presents to the urologist for the urologist's advice and an opinion whether a vasectomy should or can be performed (55250, Vasectomy, unilateral or bilateral [separate procedure], including postoperative semen examination[s]).
 
"This is a common presenting scenario for the urologist, and most physicians have billed the visit as a consultation," says Michael A. Ferragamo, MD, clinical assistant professor of urology at the State University of New York, Stony Brook. "Certainly if a vasectomy was contraindicated for any reason, and a report stating so was sent to the PCP, many urologists also felt that this was a consultation with an opinion requested and an opinion retuned to the PCP." 
 
However, in actual clinical practice, the PCP usually writes in his record, "To urologist for vasectomy," and this is where the problem begins for the urologist.
 
The PCP's statement does not really suggest that the PCP wants to hear the urologist's opinion. The documentation simply indicates that the PCP sent the patient to the urologist for vasectomy information and/or for the vasectomy itself.

New Policy Raises the Standard

"With the new 2006 policy expressed by CMS requiring a written or verbal request for a consultation from a PCP or other source, it will now become more difficult for the urologist to defend or substantiate a consultation without this formal request, and many urologists will now feel obliged to bill a new patient visit (99201-99205) instead of a consultation when seeing these patients sent for vasectomy, and I agree," Ferragamo says.
 
This initial visit to the urologist includes an explanation and counseling session, as well as a physical examination. The urologist uses the history and examination to determine the patient's suitability for a vasectomy and to uncover any emotional or physical contraindications to the surgery. Unless a formal request has been made, the PCP will no longer be involved with this patient's vasectomy.
 
Coding solution: If you see a new patient for a vasectomy visit, you should report a new patient visit (99201-99205), unless the urologist has seen the patient within the past three years, in which case you should report an established patient visit (99211-99215).
 
Why you shouldn't report a consult: In addition to the above, the point of a consultation for CPT coding purposes is that the specialist is being asked to render advice and/or an opinion.
 
In this case, the PCP's chart would state that the patient was referred to the urologist for a vasectomy. It will not state that the patient was referred for a problem that has an as-yet unknown treatment that requires the urologist's advice or opinion.

4. Pre-Op Consults Are Billable, but Know the Ropes

Question: Last year we treated a patient surgically for a urinary fistula. The patient is now going to another physician for a new pregnancy and expects to undergo a  c-section soon. The surgeon asked our urologist to clear the patient for surgery to ensure that the fistula has resolved. Can we code a consult for this clearance?

Answer: If your documentation is pristine, then yes, you can code a consult when another physician requests your opinion on a patient's fitness for surgery. CMS guidelines dictate, "Preoperative consultations are payable for new or established patients performed by any physician or qualified NPP at the request of a surgeon, as long as all of the requirements for performing and reporting the consultation codes are met and the service is medically necessary and not routine screening."
 
Look out: Before you report that consult code, make sure the surgeon is indeed requesting your urologist's opinion for a good medical reason. It's not uncommon for a surgeon to get a medical review from another physician as a preventive measure due to hospital guidelines or out of good general medical practice, says Eric Sandhusen, CHC, CPC, director of reimbursement, HIPAA and fiscal compliance for the Columbia University department of surgery in New York.
 
But if the urologist's documentation simply states, "surgical clearance," an auditor may question the motivation. Make sure the requesting physician and your urologist both document the specific reason that the patient requires clearance, such as a history of a urinary fistula.

5. Use E/M for Patient-Generated Second Opinions

Question: I know that CPT deleted the confirmatory consult codes for billing second opinions, but I'm not sure how we should report these services now. Would you advise me how I should report our urologist's work performing a second opinion?

Answer: If a patient presents to your practice and requests a second opinion, you should report the appropriate E/M code (99201-99205 for new patients, 99212-99215 for established patients).
 
Why isn't 99211 listed? According to CMS Transmittal 788, "The CPT code 99211 is not recognized by Medicare for a consultation service since this service typically does not require the presence of a physician or qualified NPP and would not meet the criteria."
 
Because most second-opinion requests are patient-generated, you should treat these office visits as you would any other E/M visit.
 
Caveat: In some rare cases, you may encounter a physician-generated second- opinion request that can qualify as a true consultation. According to CMS' Transmittal 788, "In a facility setting, a second-opinion consultation arranged through the attending physician shall be reported by a physician/qualified NPP using an appropriate initial inpatient consultation code [99251-99255] when the consultation requirements are met. When consultation requirements are not met the Subsequent Hospital Care codes (99231-99233) in the hospital setting and the Subsequent Nursing Facility Care codes (99307-99310) in the NF setting shall be reported."

Know When a Physician-Requested Second Opinion Is a Consult

For example: A general surgeon performs a colon resection. After the surgery, the general surgeon suspects that he may have injured the patient's ureter during the procedure. That evening he consults with the on-call or in-hospital urologist concerning the possibility of an intraoperative ureteral injury.
 
The next morning, the patient is still exhibiting symptoms of a possible injured ureter, and the general surgeon asks a second urologist, your urologist, for his opinion on the patient's condition. Your urologist examines the patient.
 
This scenario brings up several points of interest with respect to proper coding and a possible denial of reimbursement. Although your urologist offered a second opinion on the patient's condition, this second-opinion request was physician-generated, not patient-generated.
 
Therefore, if your physician met all of the requirements of an inpatient consultation, you may report 99251-99255 for the service.

Pay Attention to How Many People Bill Inpatient Consults

However, if the on-call urologist bills for his consultation after seeing the patient, only his claim will be paid because most carriers, including Medicare, will reimburse for only one consultation during the same admission.
 
That is, payment will be made for the initial consultation, and your claim for your urologist's second-opinion consultation will be denied. To collect for your work, you may be forced to bill only a subsequent hospital visit (99231-99233) for your urologist's service.
 
Note: If your urologist performed an immediate repair of the patient's ureter, you should append modifier 57 (Decision for surgery) to the inpatient consultation or subsequent hospital visit code and report the appropriate ureter repair code as well (such as 50900, Ureterorrhaphy, suture of ureter [separate procedure]).

Up next month: Should you hire an outside collections company or keep your collections in-house? We'll help you decide.