Urology Coding Alert

Learn what codes you'll use in 2006 instead of 99261-99263 and 99271-99275

If your urologist provides consultations, take note of the CPT deletions of follow-up and confirmatory consultation codes that go into effect on Jan. 1. Bonus: These changes mean you may actually see $10 to $12 more on each inpatient follow-up visit.

CPT Codes 2006 Also Clarifies Modifier 25

When the CPT Updates take effect, urologists will face two major E/M changes. CPT 2006 will:

• delete follow-up inpatient consultations (99261-99263, Follow-up inpatient consultation for an established patient ...) and confirmatory consultations (99271-99275, (Confirmatory consultation for a new or established patient ...).

• clarify modifier 25’s (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) explanatory text to specify that documentation must support the significant and separate E/M claim.

What You Should Report Instead

Remember that you will begin reporting all follow-up inpatient care with subsequent hospital care codes 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...), but the deletions don’t change the way you report the physician’s initial inpatient consults. You will continue to bill those as 99251-99255 (Initial inpatient consultation for a new or established patient ...).

“Elimination of the follow-up inpatient consultation codes should actually make coding of inpatient visits easier for physicians,” says consultant Jean Acevedo, LHRM, CPC, CHC, of Acevedo Consulting Inc. in Delray Beach, Fla.

How it works: When your urologist receives a request for a consult in the inpatient setting, you may claim an initial inpatient consult (99251-99255) for the visit. If your physician sees the same patient during the same inpatient stay, you should report subsequent hospital care codes (99231-99233), not follow-up inpatient consult codes (99261-99263) as you would have in 2005, Acevedo says.

Example: After a urologist renders an opinion on a patient with elevated prostate specific antigen (790.93), the physician continues to check on the patient, ordering tests and arranging further evaluations during his hospital stay. Because the urologist is managing the patient’s subsequent urological care, you should code all subsequent visits by the urologist using 99231-99233.

Deletions Increase Payment but May Cause Confusion
 
While the 2006 deletion of 99261-99263 and 99271-99275 is sure to make your coding easier and more profitable in some ways, it may also make some aspects of your coding more complicated.

Advantage: Luckily, this change will result in a pay increase for your physician--codes 99231 and 99233 pay $11.75 more than 99261 and 99263, based on the 2005 fee schedule. And 99232 reimburses $10.23 more than 99262.

Your practice was actually losing money when you chose to report a follow-up consultation when your physician performed an E/M service subsequent to an inpatient consultation, Acevedo says.

Problematic: There is no clear answer as to which code you should use instead of the deleted confirmatory consultation codes. A confirmatory consultation could qualify as an office visit, an outpatient consultation or an inpatient consult, says Heather Corcoran, coding manager at CGH Billing in Louisville, Ky.

If the patient is seeking a second opinion before surgery, and the visit meets all the requirements for a consult initiated by another physician, bill it as an office or inpatient consult (99241-99245 or 99251-99255) based on the place of service. Otherwise, bill it as a new patient office visit or inpatient care (99201-99205 or 99231-99233).
 
If the physician, or another physician of the same specialty within the group, has seen the patient within three years, you should use the established patient visit codes (99211-99215), Acevedo says.

How the patient came to see the doctor and the setting of the visit will drive the type of E/M service you report, Acevedo says. To determine the appropriate code, look at the encounter’s site of service and its consultation qualifications. If the visit meets a consultation’s three requirements--request for opinion, rendering of services, and reporting back to the requester--you should report a consult code.

Caution: Remember that some carriers will not reimburse for a second urological consultation from a second urologist if the patient has the same problem or diagnosis, or if the consultations fall within a specific time period. You may want to request that the patient sign an advance beneficiary notice (ABN) if you suspect non-payment because of this.

Additional E/M CPT Changes