Urology Coding Alert

Cut through the confusion with these tips

Several managed-care providers and private carriers will not reimburse for vasectomies for elective sterilization. What's a coder to do to get the most from this common elective procedure?
 
The keys are documentation and knowing your carrier's definition of a consult versus a new/established patient visit.

Linking Is Critical

The ICD-9 Code most appropriate for the prevasectomy examination - whether it's a consultation or a new/established patient visit - is ICD-9 V25.09 (Encounter for contraceptive management; general counseling and advice; other).
 
But you should also link V25.2 (... sterilization) to the vasectomy procedure (55250, Vasectomy, unilateral or bilateral [separate procedure], including postoperative semen examination[s]).
 
Linking the V code to the procedure is critical because it adds specificity, according to Morgan Hause, CCS, CCS-P, coding compliance specialist for Urology of Indiana. "We asked each of our contracted payers about this specifically, and nearly all instructed us to use V25.2 on the office visit as well as the visit for the vasectomy," he says.
 
"The problem," Hause adds, "is that the V code V25.09 can be used to describe a variety of reasons for care related to contraception management."
 
So for plans that specifically allow for vasectomies, payers cannot discern if V25.09 is intended for a prevasectomy visit and consequently deny it, he says.
 
In the past, many carriers did not pay for vasectomies, treating them as elective procedures, but don't presume that is still the case.
 
"Many payers (and in some cases state law requires coverage) will now pay for vasectomies but might not pay for things such as family-planning sessions, which is why we get denials for clarification," Hause says. Check with your providers to see if they want you to use V25.2 on these office visits and vasectomies.
 
Alice Kater, CPC, of Urology Associates of South Bend in Indiana, offers a variation on this method. She uses CPT 99202 (Office or other outpatient visit for the E/M of a new patient ...) for the E/M encounter (vasectomy consult) and V25.2 as the diagnosis.
 
"We are in Indiana and have had no problems with reimbursement," Kater says, "and we do see quite a bit of BCBS of Michigan since we are just over the state line."

Know the Criteria for a Consult

Much of the confusion begins with the question: Is it a consult or a new patient visit?
 
Should urologists treat initial patient visits for the vasectomy consult as a true consult as defined by Medicare or should they bill it as a new patient visit?
 
Like many coding issues, the answer is not black and white. But there are criteria you can use to determine the correct code. At issue is the slightly higher reimbursement assigned to consultation codes.
 
Many coders, relying on CPT and the Medicare Carriers Manual, say the initial vasectomy visit is not a consultation for two related reasons: (1) The primary-care physician is transferring the care of the patient to the urologist, and (2) the primary-care physician is not asking for the urologist's opinion or advice about a vasectomy.
 
Urologists say there is no transfer of "complete" care for the initial vasectomy visit, and therefore the visit is considered a consultation.
 
The consult "opinion and advice" requirement is satisfied, urologists contend, because the work they do at the initial encounter with a vasectomy patient includes giving their opinion regarding whether the vasectomy should be done.
 
They point out that they are being consulted concerning how to handle a problem.
 
No urologist would perform the vasectomy on the basis of a referral alone, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York Health Science Center in Stony Brook.
 
"The urologist must evaluate the patient physically, emotionally and psychologically to form an opinion as to the diagnosis, feasibility and suitability of the patient for the proposed surgery," Ferragamo says.
 
Therefore, this work represents a consultation, Ferragamo says, and to prove it, be sure to include a letter to the primary-care physician with the opinion confirming the consultation.
 
Remember that the urologist's opinion may contradict the performance of a vasectomy, Ferragamo says, and a letter to the primary-care provider would state this.
 
Ferragamo also stresses that Medicare's definition of a transfer of care clearly states that a transfer has not occurred simply because the primary-care provider referred the patient to the urologist for a vasectomy.
 
"To be a transfer of care and not a consultation, the primary-care provider must write to or speak with the urologist and ask him or her to accept the total care of the patient before the urologist sees the patient, and the urologist must then accept this transfer of complete care in advance - before he or she sees the patient," Ferragamo says. This rarely happens. Hence, virtually all initial vasectomy visits are consultations if referred by their PCP or another physician, many urologists say.
 
In addition, Ferragamo suggests that you not code an office visit at the time of a vasectomy if a previous encounter concerning the vasectomy has occurred and bill only for the bilateral vasectomy.

VasClips Offer Alternative

The use of VasClips rather than traditional vasectomies is a new wrinkle for coders. In a vasectomy, surgeons disconnect the vas deferens by removing a piece of vas and tying or clipping both remaining ends.
In addition, the urologist may cauterize the two ends. The new procedure clips the vas to occlude the lumen (without cutting a piece of it) to produce the same effect as a vasectomy.
 
"Use CPT code 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or other materials provided]) although some recommend A4550 (Surgical trays) (for the tray charge)," Hause says.
 
These codes for supplies are in addition to the code for the vasectomy (55450, Ligation [percutaneous] of vas deferens, unilateral or bilateral [separate procedure]), although some carriers might prefer 55250 (Vasectomy, unilateral or bilateral [separate procedure], including postoperative semen examination[s]).
 
Many carriers will reimburse $100 to $200 or more for the tray charge, including the clips. Ask your carrier whether a tray charge is a payable service.
 
These codes are consistent with what is recommended by VMBC, the company that manufactures the VasClip. They also suggest that your carrier may prefer A4649 (Surgical supply; miscellaneous) instead of A4550; this code should be reported in addition to the procedure that you performed.

Vasectomy Coding Step by Step

The first visit. Use code V25.09, and link V25.2 to the vasectomy. During this visit, the urologist discusses the procedure with the patient and, sometimes, the patient's wife. The urologist explains what the procedure entails and answers any questions he may have.
 
Coding the procedure. The procedure is coded 55250. The procedure is done under local or regional anesthesia; the anesthesia is included in the code. Usually the procedure is repeated on both sides, but because the code descriptor says unilateral or bilateral, whether you perform the procedure on one or both sides is immaterial to the code.
 
Surgical trays. Use the HCPCS code A4550 or CPT code 99070.
 
The semen analysis. After the vasectomy, the semen must be tested for sperm, otherwise you won't know if some sperm are still left.
 
Even though the vasectomy descriptor clearly includes postvasectomy semen testing, it doesn't say how many tests need to be done or how many tests the 55250 code includes, although urologists usually perform at least two.
 
Sometimes, however, the vas may recanalize. The urologist may have cut it, but it grows back. At this point there may still be sperm - another reason to do additional sperm tests.