Urology Coding Alert

Without a proven request, your consultation code could lead to an audit or fraud allegations

A primary-care physician asks a urologist to take over the complete care of one of the PCP's patients. Code this as a consultation, and you're sure to receive a denial notice and you may even open yourself up to scrutiny by the government.
 
Why? The answer is in the definitions of advice request and treatment referral. When the PCP asks the urologist to assume the complete urological care of a patient who is under the PCP's care, he is referring the patient, not asking for a consultation.

Example: An ED physician sees a patient for urinary retention, placing an indwelling Foley catheter to relieve the retention and drain the bladder. The ED physician then calls a urologist to see the patient and asks him to assume his further care. The urologist agrees, before actually seeing the patient, to accept the patient for complete urological care.

Under these circumstances, this is considered a referral, or transfer of care, and should not be reported as a consultation. In such a situation, the urologist treats the patient and supplies the continued care, rather than sending the patient back to a referring physician for continued care. Report the new patient office or outpatient codes CPT 99201 -CPT 99205 (Office or other outpatient visit for the evaluation and management of a new patient ...).

Hidden trap: If a patient visits the urologist on his own and without being sent by his physician, you cannot use the consultation codes. "Sometimes patients will come in as self-referred, and the doctors will indicate consultation," says Tina Miller, CPC, Urology Associates of Central California, Fresno. "At that point, we will often move it to initial exam   99201-99205."

Because there must be a request from a qualified medical professional, such as a physician, physician assistant, nurse practitioner, clinical social worker, podiatrist, or chiropractor, a patient's self-referral does not count as a consultation.

While this differentiation is important to remember, transfers of care or referrals are not common in urology, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook. "Most times when a physician sends you a patient, it is usually for a consultation. They want to know your opinion and advice."