Urology Coding Alert

Differing opinions make a coder's job difficult

How would you report this scenario: A patient and his wife come into your office for a prevasectomy consultation. The urologist reviews the procedure, its risks and potentials, and the patient signs any necessary releases. Should you report an office consultation (99241-99245) or a new patient office visit (99201-99205)?

The problem is that there isn't one clear, correct answer. Some urology offices use the consultation codes, and others use the new patient codes. Neither option is wrong, and experts even disagree on which option is better.

Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist practice in Indianapolis, believes that the new patient office visit codes are the best fit in the above case. "In our practice, we consider it a new patient because the referring entity really isn't asking for an opinion," he says. "He's referring that patient to get a vasectomy, and typically the patient makes the final decision."

Note: If the patient is new to your office, report a new patient visit using codes 99201-99205. If the urologist (or another urologist in the same practice) has seen the patient within the past three years, however, report an established patient office visit (99212-99215), not a new patient visit.

Others disagree. Many experts believe the pre-vasectomy visit constitutes a consultation if another physician, such as his primary-care physician or his wife's gynecologist, has sent the patient to your office. Physician Reimbursement Systems in Denver, Ray Painter, MD, and many urologists active at the American Urological Association suggest reporting this way, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York in Stony Brook. "The requesting physician is really sending the patient to the urologist, who will make a judgment whether a vasectomy is indicated and who will then relate these findings and opinions back to the primary physician, indicating for or against the vasectomy."

Review Consult Requirements First

To use consult codes 99241-99245, you must be sure that the criteria for consultations are met. There must be a documented request from the requesting physician, a record of the urologist stating his findings, opinions, and advice in the patient's chart, and a report that's sent back to the requesting doctor. See the article "Ask Where Urologist Provided Service to Nail Down Code" in the August 2005 Urology Coding Alert for more on consultations.

Word to the wise: "Physicians are not clear on how to document this particular visit," says Chandra Hines, business office manager for NC Urological Associates Inc. in Raleigh, N.C. Without proper documentation, be cautious in reporting consultation codes, but if your documentation meets the necessary criteria you can consider reporting a consultation code.

Best bet: Since even experts disagree on whether the prevasectomy visit constitutes an office consultation or an office visit, you should contact your individual carriers to determine which codes they prefer.