Urology Coding Alert

And regulators are paying close attention to these services

Coding consults and referrals is often confusing for even experienced coders. But with increasing attention being paid to consultations by the Department of Health and Human Services' Office of the Inspector General (OIG) and private carrier auditors, you need to be crystal-clear on the rules for coding this service.

What's in a Name? Defining Consults and Referrals

A consult is a service rendered to give an "opinion or advice" to a requesting physician about a patient's diagnosis or treatment. A referral, on the other hand, is the transfer of responsibility for a patient's care from one physician to another.
 
In 1999, CPT Codes and CMS, in an attempt to clarify these criteria, stated that a transfer of care occurs when a physician asks, verbally or in writing, the urologist to assume "complete urological care" of the patient, and the urologist accepts to provide this patient care before and in advance of seeing the patient.

Remember the Three R's

But consultation criteria must be satisfied. There must be a request from a physician or other source; a reason for the request, with a recording or documentation of such in the medical record; and a separate written consultation report sent back to the requesting physician or other source.
 
A primary-care physician usually brings in a urologist for a consult, but a variety of sources can request a consult - podiatrists, chiropractors, clinical social workers, a physician assistant, or a nurse practitioner.
 
Note: A nurse cannot request a consultation for payment purposes.
 
Typically the requesting physician sends the patient to the specialist, the specialist provides his opinion concerning diagnosis and/or treatment and, at the conclusion of the consultation, sends the patient back to the requesting physician.
 
A consultation can be rendered for a new patient or an established patient. A urologist may see a patient in consultation and then decide after the visit to take over and render treatment. You can still code this first encounter as a consultation with follow-up visits as subsequent care.
 
A urologist may also render a consultation and order diagnostics tests, in which case you should still report the visit with a consultation code. But remember that all criteria for a consultation must be met and, most important, without a "request" for your opinion or advice, there can be no consultation.
 
Billing for a consultation when the service provided doesn't meet the definition of a consult can land a practice in hot water with the OIG and with their state attorney general - not to mention invite an audit.

Know Your Codes

 CPT includes four types of consultations:
 

Office or other outpatient (99241-99245)
 

Initial inpatient (99251-99255)
 

Follow-up inpatient (99261-99263)
 

Confirmatory (99271-99275).

For pure referrals, use a new patient office visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient). In such a case, the specialist assumes care for the patient's problem, which often involves subsequent visits, surgical procedures, ongoing treatment, or follow-up care.

Watch Your Language

The wording in your documentation is critical to providing an accurate record of the patient's treatment.
 
Always make sure you document the request for a consultation in the patient's record, whether the initial request was verbal or written, says Morgan Hause, CCS, CCS-P, CPC, at Urology of Indiana.
 
Demonstrate that the request was made by the other physician. Make sure it's noted in the schedule. Carriers require this documentation to consider the consult code valid. Under the best circumstances, documentation of this request should be kept in the patient's charts.
 
The wording of the request is important. Physicians should avoid using the word "referral" when they are actually requesting a consultation. Use of this word can imply a transfer of care and be a red flag to auditors.
 
Use the term "consult" in the request, a tactic that makes the nature of the visit very clear should there ever be an audit of the information.
 
Physicians reporting back to the requesting physician following a consultation should be careful with using the term "refer." In many cases, you will have the specialist write a note that says, "Thank you for referring Anne Smith to me. I will be following her for such and such a problem." Consider using something like "Thank you for your request to render a consult." Here there is no doubt about the nature of the visit.

Keep Doctors Informed

"We have this discussion about once a year with the doctors," says Sue Hineline, CPC, at Bellevue Urology Associates in Washington state. "We tell the doctors that to bill for a consultation we need to write in the chart note 'Thank you for the consult' or 'This is the consult you requested.' " Following a consultation, the urologist may decide to take over the care of the patient, but the initial billing should still be for a consultation if all the criteria are met.
 
For example, a urologist asks a nephrologist for a consult. The nephrologist completes the consult, fulfilling the requirements of the service, including sending the report to the requesting physician.
 
In the course of evaluating the patient, the specialist decided that he should follow the patient's care for the particular problem. In his note to the original physician, he should state this fact and be sure to thank the urologist for the consultation.

Cut Your Losses With Some Procedures

Some procedures such as vasectomies cause confusion as well, Hause says. "There's some disagreement out there in the world about whether a vasectomy referral is a consult or not. We do not consider it a consult. We bill it as a new patient, or an established patient if we've seen him in the last three years. Vasectomy is an elective procedure," Hause says. "Our theory is that the referring physician isn't really meeting the requirements of asking for an opinion."
 
No surgeon or urologist will perform a surgical procedure without first reaching an independent opinion as to the indications for the surgery.
 
The primary-care physician is certainly not completely versed in the indications for surgery, and when "sending a patient for a vasectomy," he is really asking the urologist for his opinion concerning the feasibility of a vasectomy for this particular patient. At times the urologist may say that a vasectomy should not be performed.