Urology Coding Alert

Vasectomies are commonplace in most urology Practices. But choosing the proper codes to report can prove challenging, starting with the pre-vasectomy "consultation" visit most urologists perform. If you're not billing out each piece of the vasectomy process, you could be costing your practice hundreds over the course of one year. Follow these four steps to ensure you capture all the reimbursement your urologist deserves.

Before a urologist performs a vasectomy, he usually meets with the patient to discuss the procedure and ensure that the patient understands the consequences of the procedure and wishes to undergo this elective sterilization. You'll report this office visit using the appropriate E/M code, says Kelly Young, a coder with Scottsdale Center for Urology in Scottsdale, Ariz.

The coding challenge comes when you try to determine whether you should be reporting an office visit E/M code or a consultation code.

Depending on your urologist's documentation, you'll choose from the consultation codes (99241-99245, Office consultation for a new or established patient ...), a new patient (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...), or established patient (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) codes.

See the dollar signs: If you skip reporting the pre-vasectomy office visit, you're forfeiting money. For example, if your urologist performs a level-three new patient visit (99203), you'll earn $91.97 (the unadjusted fee for 99203, 2.55 RVUs, times the 2009 conversion rate of $36.0666) in addition to the procedure code, and if your urologist performs a level-three consultation, you'll earn $125.15 (the unadjusted fee for 99203, 3.47 RVUs, times the 2009 conversion rate of $36.0666) in addition to the procedure code.

Keep in mind: If the patient is new to your office, report a new patient visit using codes 99201-99205. If the urologist (or another urologist in the same practice) has seen the patient within the past three years, however, report an established patient office visit (99211-99215), not a new patient visit.

Caution: Don't let the term "consultation" in the physician's documentation trick you. Often practices, physicians, and even patients refer to the pre-vasectomy visit as a consultation. However, to report a consultation code (99241-99245), the visit must meet the requirements of a consultation. There must be a documented request from the requesting physician; a record of the urologist stating his findings, opinions, and advice in the patient's chart; and a report that's sent back to the requesting doctor.

"Since the recent rule changes for consultations come from Medicare 2006 policy changes, Transmittal 788, and since most men seeking vasectomies for sterilization do not have Medicare as their primary insurance carrier, patients sent to urologists by physicians most often represent consultation requests and should be billed and coded accordingly if all criteria for a consultation are met," says Michael A. Ferragamo MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook. For more on consultation coding guidelines, see "3 Expert Answers Can Relieve Your Consultation Coding Fears" on page 61.

Diagnosis help: The ICD-9 code most appropriate for the pre-vasectomy examination -- whether it's a consultation or a new/established patient visit -- is V25.09 (Encounter for contraceptive management; general counseling and advice; other).

Remember: Many payers view code V25.09 as "family planning advice," pertaining only to the female partner, and they will deny payment for any pre-vasectomy examination of the male when you use this diagnosis. In its place, use V25.2 (Encounter for contraceptive management; sterilization, admission for interruption of ...vas deferens). In most cases you can expect payment for a pre-vasectomy service with this diagnosis.

Check with your payer to see which diagnostic code it prefers. The Scottsdale Center for Urology uses V25.2 as the diagnosis code, Young says. However, "we bill ... with V25.09," says Kim Kerckhoff, CCA, coder for Alpine Urology in Anchorage, Alaska.

Be sure to append modifier 57 (Decision for surgery) to the E/M code you report if your urologist performs the vasectomy procedure on the same day as the prevasectomy office visit. Make sure, however, that the urologist's documentation supports a separate E/M code -- the E/M service must go above and beyond the E/M that's inherent to the procedure.

Ensure separate payment: If you want to be sure your payer will not bundle the pre-vasectomy visit with the vasectomy procedure, your urologist may want to conduct the services on separate days. Many urologists do this anyway to give the patient time to review his options and make the final decision about surgery. Plus, your office will have time to review the patient's benefits. (See "Confirm Vasectomy Procedure Coverage Before Coding" on page 60 for more information.)

"We never perform the procedure the same day as the vas consult," says Alice Kater, CPC, PCS, coder for Urology Associates of South Bend, Ind. "The patient and wife/partner will come in for the consult, view a movie, [and] speak extensively with the physician following the examination and review of systems. When they leave the physician, they stop at the front desk and schedule their procedure for the next available, and convenient, vas opening."

To report the actual vasectomy procedure, you'll have to dig into the documentation to see which technique your urologist used. Then choose one of these three codes:

• 55250 -- Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s). "This CPT code is the code most commonly used for vasectomy for voluntary sterilization," Ferragamo explains.

• 55450 -- Ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure). Coders rarely use this code for a vasectomy for voluntary sterilization,Ferragamo says.

• 55559 -- Unlisted laparoscopy procedure, spermatic cord for a laparoscopic vasectomy. Link V25.2 to the vasectomy procedure, says Kerckhoff.

Pointer: You should report 55250, 55450, or 55559 just once per patient regardless of whether the urologist performs the procedure on one or both sides. The urologist usually, but not always, performs the procedure, cutting the vas deferens and suturing the ends, on both the left and right sides. Even if your urologist only cuts and sutures one side (for a patient having only one testicle), don't change your coding.

Note: These codes also include the local or regional anesthesia that the urologist administers, so do not code separately for any local anesthesia administered for those services.

Surgical trays: Use the HCPCS code A4550 (Surgical trays) or CPT code 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) for private or commercial payers, some of which will reimburse for a surgical tray/supplies.

"Medicare will not reimburse for anesthesia administered by the surgeon or urologist, or for tray charges," Ferragamo cautions. "Note, however, there are a few commercial carriers that will still reimburse for local anesthesia administered by the urologist and for a tray charge. Check with the specific carrier. One may bill private or commercial carriers HCPCS code S0020 (Injection, bupivicaine HCL, 30 ml) for reimbursement of the anesthetic agent used," he adds.

There is no CPT code for laparoscopic vasectomy so when your urologist performs this procedure, usually at the same time a general surgeon is performing a laparoscopic hernia repair, report the unlisted code 55559.

Key: Remember to submit a detailed report to your payer and compare, or benchmark, the laparoscopic vasectomy to 55550 (Laparoscopy, surgical, with ligation of spermatic veins for varicocele), with respect to the surgical work, technology, equipment used, and time involved.

After the vasectomy, the urologist must examine the semen to determine the eventual absence of sperm. These examinations are included in the procedure code, so your urologist should document the service, but you should not report them separately.

If your office laboratory is not credentialed (CLIA certification) to perform these post-vasectomy semen analyses, outside laboratory evaluations will be necessary and result in an additional cost to the patient. However, under these circumstances your urologist should never lower his fee or modify his coding. Practices can often make special arrangements with most laboratories for a reduced fee for a limited semen examination looking only for the presence or absence of sperm.