Urology Coding Alert

Bonus:  An NPP can both provide and request consultations

Many of your common--and often frustrating--consultation coding questions have now been answered, thanks to a new CMS transmittal. If your urologist provides consultations for other physicians, you'll want to use these expert tips to find out how to take advantage of the consultation clarifications and prevent denials later.

The Physician's Area of Expertise Makes a Difference

One of the most significant CMS clarifications made in Transmittal 788 says that if your urologist works in a group practice, you'll now be able to report and be compensated for consultations that he provides for other physicians in the group. The key point is that the consulting physician's knowledge and expertise must go above and beyond that of the requesting physician's.

This requirement will apply to urology groups in which the physicians have subspecialties, as well as to more diversified groups that a urologist may be part of. "While consultations within a group between separate specialties has been pretty clear, it was never clearly defined that a same-specialty consultation within the same group was allowed, provided guidelines are met," says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist practice in Indianapolis. "Many urology groups, particularly large ones with physicians who are sub-specialized, will benefit from this clarification."

For example, the urology practice Hause works for has urogynecologists and a fellowship-trained infertility specialist, so being able to have consultations between the physicians will be a plus.

Tip: Your protocol cannot be that if a patient comes in to see Dr. A, he then automatically sends the patient over to Dr. B after he finishes his examination. Make sure your office can prove that the urologists have separate sub-specialties and that there is medically necessity for the second physician to see the patient. The reason for the consultation will be diagnosis-driven, and the consultation must be medically necessary, says Christy Shanley, CPC, billing manager for the University of California, Irvine department of urology.

Transfer of Care Eliminates Code Options

Make sure you don't report a consultation if there is a transfer of care between physicians in the same group or practice, says Nancy Reading, RN, BS, CEO of Cedar Edge Medical Coding and Reimbursement in Centerfield, Utah.
 
Example 1: In a group of urologists, one provider does not perform laparoscopic procedures but another does. The first urologist sees a new patient who presents with prostate cancer. The urologist performs a prostate biopsy, which shows a tumor that the urologist doesn't feel qualified to handle. He asks the other urologist in his practice to take over the care of the patient, suspecting that the patient is a good candidate for a laparoscopic radical retropubic prostatectomy using the daVinci apparatus.

Because the first urologist sent the patient to the other physician to care for this new problem, the visit is probably not a consult, Hause says.

Example 2: A urologist sends a patient to a colleague who has specialized expertise in the management of a particular infertility problem. The requesting physician has exhausted all known treatment options and wants the consultant's opinion on further treatment options. Since this would stand up as a request for an opinion, you can report a consultation code for this visit.

Forego Split Visits for Consultations

Good news: Your nonphysician practitioners (NPP) can now report and request consultations, according CMS.
 
Bad news: The agency also clarified that you cannot report a consultation that is a shared or split visit between the urologist and the NPP. Some practices may have been previously advised by their carriers not to use shared visits for consultations, but this may be a significant change for some physicians, Hause says.

Often in urology practices a nurse practitioner performs the patient workup. The urologist then provides a key portion of the service "face-to-face" and bills for the whole visit. Shared visits such as this are not permissible with consultations. Therefore, when your urologist is performing a consultation, your office's nurse practitioner or physician assistant can only perform the review of systems or past medical, family and social history.