Urology Coding Alert

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The frequency in which you report a range of evaluation and management (E/M) codes will often impact your knowledge and understanding of the rules that accommodate each E/M subsection. That’s why you might find yourself needing to review the guidelines when your provider performs an intermittent interprofessional telephone/internet/electronic health record physician-to-physician consultation, relays Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York Stony Brook.

When coding for these services, you must take numerous details and components of the exchange into account to reach the correct level of service. What’s more, coders for physicians on both ends of this exchange need to know what details to look out for to get the coding mechanics down pat.

Utilize all the necessary guidelines — and a helpful example — to code these special consultation services accurately and confidently.

Report These Consultation Codes Under Appropriate Circumstances

In some instances, a treating urologist may reach out to a more specialized provider within the same specialty, or a provider of a different specialty, to discuss diagnostic and/or treatment management of a patient’s condition. So long as a strict set of criteria are met, both providers can bill for these services in some capacity using codes from the respective E/M subsection.

Scenario: For example, if a urologist consults with a requesting physician using audiovisual, telephone, or a virtual form of communication, the urologist may report one of the following consultation codes so long as a strict set of criteria is met:

• 99446 (Interprofessional telephone/Internet/ electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review)
• 99447 (… 11-20 minutes of medical consultative discussion and review)
• 99448 (… 21-30 minutes of medical consultative discussion and review)
• 99449 (… 31 minutes or more of medical consultative discussion and review)

You can find the complete set of criteria surrounding these codes on page 41 of the 2020 CPT^® code book. This includes a variety of useful guidelines you should adhere to when coding for a consulting provider. For instance, the patient may either be new or established to the consulting provider, but the consulting provider may not bill for the service if they have seen the patient within the past 14 days. The use of code range 99446-99449 should also “conclude with a verbal opinion report and written report from the consultant to the treating/ requesting physician,” according to the CPT^® code book.

To consider: According to CPT^® guidelines, 99446-99449 should conclude with a “verbal opinion report and written report from the consultant to the treating provider.” Furthermore, if more than 50 percent of the consulting physician’s time is dedicated to data review and/or analysis, codes 99446-99449 are not eligible for reporting. Instead, you should opt for code 99451 (Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time).

Advice: “Do not confuse 99446-99449 with code ranges 99441-99445 and 99551-99555, which are not paid by Medicare Part B in addition to other non-Medicare payers,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey.

Factor in Time, Authoritative Guidance for Requesting Physician Coding

While the coding dynamics surrounding the consulting provider’s services are relatively straightforward, there isn’t as much guidance on how to proceed for the complete services involving the requesting physician. First, it’s important to understand that codes 99446-99449 are intended for billing by the consulting provider, not the requesting provider.

However, the requesting provider may still bill for services in requesting a consultation from another provider. CPT^® Assistant (October 2013; Volume 23: Issue 10) elaborates on this topic by explaining how a requesting provider should bill for services when the exchange between requesting and consulting physician extends beyond 30 minutes: “The treating/requesting physician or other qualified health care professional may report the Prolonged Service With Direct Patient Contact codes (+99354-+99357) for the time spent on the interprofessional telephone/Internet discussion with the consultant (eg, specialist) if the time exceeds 30 minutes beyond the typical time of the appropriate evaluation and management (E/M) service performed and the patient is present (on-site) and accessible to the treating/requesting physician or other qualified health care professional. If the interprofessional telephone/Internet assessment and management service occurs when the patient is not present or on-site, and the discussion time exceeds 30 minutes beyond the typical time of the appropriate E/M service performed, then the Prolonged Service Without Direct Patient Contact codes (99358, +99359) may be reported by the treating/requesting physician or other qualified health care professional.”

This means that a requesting provider may include up to the first 30 minutes of dialogue between requesting and consulting provider into the typical time estimate for the underlying E/M service that resulted in the consultation request. However, you’ll want to know how to proceed when the provider’s typical time estimate extends beyond the time estimate for the highest-level E/M service, but the discussion between requesting and consulting provider does not exceed the threshold 30 minutes.

Round Out Your Knowledge Using This Example

Example: A urologist performs an E/M visit for an established female patient with documented bladder stones during pregnancy. The visit lasts 40 minutes. Immediately following the visit, the urologist requests a consultation with an obstetrician to discuss the added risks of performing a bladder lithotripsy on a patient in her second trimester. The phone call lasts 20 minutes and the obstetrician spends another 10 minutes writing a review to be sent to the urologist.

In this instance, the consulting obstetrician will report code 99448 for 30 minutes of total time spent. To reach the correct E/M code for the urologist, you’ll want to total the amount of time spent during their office visit and the time spent conversing with the consulting obstetrician.

If documentation supports that the encounter met the 50 percent threshold for counseling and/or coordination of care services between the E/M visit and the consulting physician discussion, you may report an E/M level of service code 99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) since the visit lasted 40 minutes.

However, you’ve still got 20 additional minutes you need to account for during the phone call. With respect to prolonged E/M services code +99354 (Prolonged evaluation and management or psychotherapy service(s) …), you may not report this code without reaching a total duration of 30 minutes or more of prolonged service time. Since the requesting physician did not reach 30 minutes of dialogue with the consulting physician, you may not report +99354 or 99358 with 99215, per CPT^® guidelines.

Note: Remember that CMS will do away with the 50-percent threshold for time-based coding of office/ outpatient visits with the revised 2021 E/M guidelines.

Now, consider the same scenario as above, except the duration of the phone call between requesting and consulting provider lasts 30 minutes. Here, you’ll code for the consulting obstetrician’s services totaling 40 minutes (including the 10-minute written review) using code 99449. Assuming the requesting urologist is able to code using a typical time estimate, they will report code 99215. Next, since the urologist has reached the 30-minute threshold of non-face-to-face prolonged services, you may report code 99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour) alongside 99215.