Urology Coding Alert

Follow these expert guidelines to get your share of high-paying E/M services

The urologist is called to the emergency department to consult on a patient's diagnosis and concludes that the patient is well enough to go home. You report consultation code 99251, but all you get is denied.

To avoid denials like these, you need to know CPT's criteria for a consult. If the consultation a urologist performs doesn't meet the criteria of the consult you report, you could be receiving reduced reimbursement, or worse, outright denials.

Our experts explain how the critical "Three R's" and differentiation between inpatient consultations and follow-up consultations can make or break your consultation reimbursement.

The first step to determining which type of consult code to report is knowing where the urologist was. Just like the office visit E/M codes (CPT 99201 -CPT 99215 ), the level of consult code you choose within each type depends on satisfying a certain number of key components in the history, examination, and medical decision-making.

Office or Outpatient Consultations

Report 99241-99245 (Office consultation for a new or established patient ...) for consultations in the office, in the ED when the patient is not admitted, or in the outpatient department of the hospital.

Example: An emergency department physician calls the urologist to consult on the diagnosis of a patient who has abdominal and flank pain. The urologist diagnoses renal colic (788.0) and advises that the patient is doing well enough to go home. Report the appropriate level of office or outpatient consultation code (99241-99245).

Inpatient Consultations

Submit codes 99251-99255 (Initial inpatient consultation for a new or established patient ...) for consultations regarding patients in hospitals, nursing homes, or skilled nursing facilities.

Example: The urologist is called to the ED in consultation for a patient with abdominal and flank pain, along with a low-grade fever. The urologist diagnoses renal colic (788.0), and recommends that the patient be admitted to the hospital because of the fever and a need for IV fluids. Report 99251-99255 for the urologist's first hospital visit, with the emergency physician as the requesting physician. Report subsequent hospital care with 99231-99233.

Follow-Up Consultations

Report codes 99261-99263 (Follow-up inpatient consultation for an established patient...) for follow-up inpatient consultations.

Example: The urologist performs a consultation in the hospital. Later, during that same patient's hospital stay, the requesting physician calls the urologist back for further advice concerning a change in treatment. Report 99261-99263 for this follow-up in-hospital consultation.

However: In these cases, urologists often use the higher-paying codes 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) because it is difficult to determine if a second visit with a patient actually qualifies as a follow-up consultation, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook.

A urologist can report a consultation code only once per hospital stay, but "because a follow-up inpatient consultation constitutes a subsequent hospital visit, you may use codes 99231-99233," he says.

Be prepared: "Codes 99261-99263 will be deleted in 2006," Ferragamo says, "so next year 99231-99233 will be the only coding option for this type of follow-up visit."

Confirmatory Consultations

Report codes 99271-99275 (Confirmatory consultation for a new or established patient ...) for confirmatory, or "second opinion," consultations. A patient, his family, or sometimes the primary-care physician may initiate a confirmatory consultation seeking a second opinion.
 
The only service the urologist provides in a confirmatory consultation is an opinion, usually concerning a proposed treatment or diagnostic study. This type of consultation can be either inpatient or outpatient.

Example: A urologist advises a patient to undergo a radical prostatectomy for a diagnosed carcinoma of the prostate. The patient seeks the opinion of another independent urologist about the diagnosis and treatment. The second urologist comments and gives his opinion and advice on the proposed treatment plan, but does not assume the care of the patient. Code this visit as a confirmatory consult (99271-99275).

Identify What Makes a Consultation

A consultation is a request for an opinion or for advice. There are three criteria, also known as the Three R's, that must be satisfied for a consultation.

First, there must be a request for the consultation. This request can come from anyone who is paid directly by an insurance carrier, such as the physician, physician assistant, or nurse practitioner, and the request must be noted in the patient's chart. "Make sure that you have the name of the referring doctor or nurse practitioner," says Tina Miller, CPC, Urology Associates of Central California, Fresno. Without a specific, documented request from another medical professional, you can't use a consultation code. A specific written request for a consultation from a physician is not necessary, but a statement of this fact should appear in the medical records.

Second, the consulting physician needs to record his findings, opinions, and advice in written form in the patient's medical record. Finally, a written report must be submitted to the requesting physician. Both the requesting physician and the urologist should keep a copy of this report.

Be sure the urologist satisfies each of these three criteria before you submit a consultation code. "I believe the biggest mistake made with regard to consultations is not completing the circle of 'primary-care physician to specialist back to PCP,' " says Alice Kater, CPC, coder for Urology Associates of South Bend, Ind. "This documentation is mandatory to support the consultation codes."