Urology Coding Alert

Skipping the pre-vasectomy visit coding will cost your practice up to $180. 

Vasectomies are often common place in urology practices, but if your diagnosis code choices do not support medical necessity for the procedure, your urologist could be performing these procedures for free. 

Read on to garner expert tips to ensure the documentation, diagnosis coding, and procedure coding hold up for not only the procedure, but also the pre-procedure office visit. 

1. Start with the Consultation

Before a urologist performs an elective vasectomy, he usually sees the patient in the office. During this visit, the urologist examines the patient and discusses the procedure with the patient and, sometimes, the patient’s family. The urologist explains what the procedure entails and answers any questions he may have.

Consult or new patient? One of the first questions coders must ask, is whether this visit should be reported with a consultation code (99241-99245, Office consultation for a new or established patient ...) or a new patient visit code (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...). 

Many coders, relying on CPT® and the Medicare Carriers Manual, believe 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.

“We report 99202 to 99204, depending on provider documentation,” says Leah Gross, CPC, CUC, coding lead at Metro Urology in St. Paul, Minn.

“The office visit prior to a vasectomy is usually billed at one of the lower levels (99212 for established patients, 99241/99242 for consults, or 99201/99202 for new patients),” says Teresa A. Dailey, CPC, coding specialist for Urology Center of Spartanburg in South Carolina. (Note: Remember that, if your urologist performs a full examination which he feels is necessary because the patient is to have surgery, levels 3 and 4 may be appropriate if properly documented.)

In addition, many urologists feel that the criteria for a transfer of care have not been met with this clinical scenario, (i.e., no pre-visit request from the primary care physician has been made to the urologist to assume patient care) and thus, there is no real transfer of “complete” care for the initial vasectomy visit. 

According to some experts, however, in this scenario the decision for a transfer of care is made by the urologist after his initial office visit with the patient. This initial visit should be billed as a consultation according to CPT® guidelines. Therefore, the visit is considered a consultation. The consult “opinion and advice” requirements are satisfied since the initial encounter with a patient includes the urologist’s opinion regarding whether the vasectomy should in fact be performed.

While many experts still disagree on the proper coding, you can turn to your payer for the answer. If the payer no longer accepts the consultation codes, then you have no choice but to report a new patient code. 

Pointer: In most cases, a urologist’s established patient who regularly sees his urologist would know that if he wants a vasectomy, and usually does not discuss this with his primary care physician, but rather he can go directly to his urologist. This encounter is an established patient visit, which you would report with 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...), says Chandra L. Hines, practice manager of Capital Urology, Wake Physicians Practice in Raleigh, NC. 

2. Focus on Procedure Type

For a standard vasectomy or the new “no scalpel” technique vasectomy, report 55250 (Vasectomy, unilateral or bilateral [separate procedure], including postoperative semen examination[s]). 

There is no CPT® code for a laparoscopic vasectomy. However, when your urologist performs this procedure, most often at the same time as a general surgeon is performing a laparoscopic hernia repair, report the unlisted code 55559 (Unlisted laparoscopy procedure, spermatic cord) for the vasectomy.

Bilateral: Usually the urologist performs a vasectomy for voluntary sterilization is performed on both sides, although the code descriptor indicates that this code may be used for unilateral or bilateral procedures. Additionally, the use of local or regional anesthesia administered by the operating surgeon is included in the code and is not separately billable or payable. 

3. Confirm Dx with Your Payers

The ICD-9 code that is most appropriate for the pre-vasectomy examination — whether it’s a consultation or a new/established patient visit — is V25.09 (Encounter for contraceptive management; general counseling and advice; other). You should link V25.2 (... sterilization) to the vasectomy procedure. 

Note that some payers link ICD-9 code V25.09 with only female patients and therefore, may deny payment if used for a vasectomy office evaluation. In these cases, use V25.2 for both the visit and the vasectomy itself. Nevertheless, be sure to check the coding with your payer.

4. Verify Coverage Before Surgery

In the past, many payers did not reimburse for voluntary sterilization, treating them as elective procedures, but don’t presume that is still the case. “We rarely see vasectomies denied,” Gross says. “Once in a while we have a random insurance or a random policy that will not reimburse for either the vasectomy or the vasectomy consult. It is never a common policy, thankfully.”

“The only trouble I’ve experienced is with Medicaid patients because they have to sign a form for sterilization and have to wait 30 days before the procedure can be done,” Dailey explains.

However, keep in mind that if the primary reason for a vasectomy is for sterilization, Medicare will not pay. “Payment may be made only where sterilization is a necessary part of the treatment of an illness or injury,” says the CMS National Coverage Determination (NCD) for sterilization. 

“Your best bet is to get a signed ABN before the procedure,” Gross advises. 

“As with any elective procedures, we always check benefits,” Hines explains. “We discuss with patients our procedure and let them know the estimated out of pocket is due upon registration at time of procedure.”

Involve the patient: You can get your patient to help you determine whether the insurance company will cover the vasectomy procedure. “We tell every patient to call their insurance company to check for coverage ... We provide the patient with the code and the corresponding prices for the two types of vasectomies so they have all the information needed to call their insurance company and make a decision,” Gross says. “We also provide the phone number to the hospital or surgery center the procedure will be performed at when it cannot be done in the office, so the patient can get an estimate of his facility fees. We document that the conversation happened so that if the patient does not call his insurance and he ends up with a big bill, he cannot claim he was not informed.”

“My best advice is to check with the patient’s insurance prior to scheduling and be specific with your questions,” Dailey says. “Ask if a vasectomy is a covered procedure, if it is covered as an in office procedure or if it is done in an ASC, and even ask if there is an exclusion for infertility.”