Urology Coding Alert

When a primary care physician (PCP) sends a patient to the urologist because the patient wants a vasectomy, coders face with the challenge of whether to code the initial visit as a new patient visit or as a consultation. Like many coding issues, the answer is not black and white. But there are criteria coders can use to determine the correct code for proper reimbursement. At issue is the slightly higher reimbursement afforded by consultation codes.

Coders, relying on CPT and the Medicare Carriers Manual, say the initial vasectomy visit is not a consultation for two related reasons: (1) the primary care physician is transferring the care of the patient to the urologist and (2) the primary care physician is not asking for the urologists opinion or advice about a vasectomy.

The primary care physician has no intention of doing the vasectomy, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding and compliance consulting firm specializing in urology and based in Denver. Proper coding convention dictates the use of the new patient codes, not the consultation codes, Page says.

The primary care physician will never do it himself, agrees Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C. Yes, ultimately the urologist has to decide whether the patient is an appropriate candidate for surgery. But the primary care physician is not asking your opinion about the vasectomy. He or she is sending a patient to you for the purpose of doing a vasectomy.

In the introduction to the consultation section in CPT Codes 2001, a consultation is described as a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. This alone is enough to indicate that the consultation codes should not be used for initial vasectomy visits, Page says.

The Urologists Viewpoint

Urologists say there is no transfer of complete care for the initial vasectomy visit, and therefore the visit is a consultation. The opinion and advice requirement is satisfied, urologists contend, by the fact that the work they do at the initial encounter with a vasectomy patient is indeed giving their opinion on whether the vasectomy should be done. They point out that they are being consulted about how to handle a problem (although Medicare, which doesnt pay for vasectomies, would question whether a problem even exists).

Urologists are taking transmittal 1644 of the Medicare Carriers Manual (issued in 1999) literally. Forget for a moment that Medicare doesnt [...]