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 cover vasectomies. Private payers often adopt Medicare rules. And proper coding is the only way to fight the private payers denials.

Medicare, in transmittal 1644, makes it clear that physicians can treat after providing a consultation, as long as there is no transfer of care. The transmittal directs carriers to pay for a consultation regardless of treatment initiation unless a transfer of care occurs, as long as the criteria for a consultation are met.

The wording of this transmittal is essential to the urologists defense for using a consultation code. Taken literally, the transmittal says that only if the urologist accepts the complete care of the patient before seeing the patient would a transfer of care occur. Since there is no such transfer of care, the urologists argue, they can bill a consultation for an initial vasectomy visit.

If the patient has no other problems that they will ever see the primary care physician about, then yes, the primary care physician is transferring care to the urologist, and the urologist cannot bill a consultation, says Ray Painter, MD, a urologist who is president of PRS, a coding, compliance and reimbursement consulting firm based in Denver. But if the encounter fits the criteria of a consultation, then it can be charged as a consultation.

No urologist would perform surgery on the basis of a referral alone, adds Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York, Health Science Center in Stony Brook. The urologist must evaluate the patient physically, emotionally and psychologically to form an opinion as to the diagnosis, feasibility and suitability of the patient for the proposed surgery. This work, Ferragamo says, represents a consultation. A letter to the primary care physician with the opinion confirms the consultation. Remember, Ferragamo says, that the urologists opinion may contradict the performance of a vasectomy, and a letter to the primary care provider would state this fact.

Ferragamo also stresses that Medicares definition makes it clear that a transfer of care has not occurred simply because the primary care provider referred the patient to the urologist for a vasectomy. To be a transfer of care and not a consultation, the primary care provider must write to or speak with the urologist and ask him or her to accept the total care of the patient before the urologist sees the patient, and the urologist must then accept this transfer of complete care in advance before he or she sees the patient. This rarely happens. Hence, virtually all initial vasectomy visits are, in the viewpoint of urologists, consultations.

Were not disagreeing with the fact that they are consultants, Page says. We have no argument with that. But for coding and reimbursement purposes, we must follow very strict guidelines. And those guidelines say that these encounters are not consultations.

Coding for Established Patients

Many urologists say that consultation reimbursements are higher than those for new patient visits. They probably are, but not by much new patient visits pay well. The established patient visits do not pay well, however.

If the urologist saw the patient within the past three years, and the patient was referred to the urologist for a vasectomy, the visit can be coded as a consultation as long as the criteria for a consultation are met. Many private payers, however, have frequency limitations on consultations, allowing only one a year per patient, or even only one every three years. In most cases, a urologists established patient would know that if he wants a vasectomy, he doesnt need to discuss it with his primary care physician, but rather he can go directly to his urologist. This encounter is an established patient visit.

There is one final issue: Private payers often require that the primary care physician give a referral in order for the patient to see a specialist. This referral has nothing to do with a request for a consultation, but is simply a way for the payer to control utilization of specialists. If the urologist is working in this kind of payer climate, even established patients will have to go to their gatekeeper first in order to go to a urologist to get a vasectomy.

On the Same Side

Morgan Hause, CCS, CCS-P, coding compliance specialist for Urology of Indiana, a 17-urologist practice in Indianapolis, does not believe that primary care physicians are asking for an opinion about whether their patients should get vasectomies. These visits, therefore, are new patient or established patient visits, not consultations.

This isnt about Medicare anyway, Hause says. So you go back to CPT, and it says opinion or advice.

There may be controversy about how to code these visits, but there are guidelines for picking a code. And regardless of the controversy, remember that urologists and coders are on the same side.