Urology Coding Alert

Tip: Check for transfer of care before reporting 99241-99245

Knowing what not to report is just as important as knowing what to report when you're dealing with prostatitis treatments. If you report a consultation code without first ensuring the office visit meets consultation criteria, or if you neglect to report signs and symptoms of prostatitis and report only a probable diagnosis, you'll be facing a slew of denials.

To be certain that you're not falling into the prostatitis coding pitfalls, follow these three expert steps.

Step 1: Look First at 99241-99245 for Initial Visit

The first time your urologist sees a patient for prostatitis will likely be at the request of the patient's primary-care provider (PCP). The PCP may request a consultation because the patient has symptoms such as frequency, urgency or dysuria, and elevated prostate specific antigen (PSA), and the prostate may be enlarged and/or extremely tender.

If the patient's visit to your office meets the consultation requirements, you should report your urologist's service with a consultation code (99241-99245, Office consultation for a new or established patient ...). (See "Keep Consultation Requirements Straight With 5 Basics" on page 92 for more on consultation requirements.)

"If a patient is in for prostatitis, with no other urological complaints, the average code we use is 99243," says Kelly Young, office manager at Scottsdale Center for Urology in Arizona.

Important: Checking the urologist's documentation is essential when selecting the appropriate consult code level. "Make sure your doctor has documented properly, especially when you are using those higher-level E/M services," Young says. "As the risk and the medical decision-making are not high on prostatitis, it is important to make sure you are choosing an E/M code that will pass an audit."

How it works: In a typical prostatitis case, if a PCP refers the patient to your urologist, the urologist will document the request and write a letter to the referring physician reporting his findings.

Remember: Your urologist can provide treatment after a consultation as long as there is no "transfer of care." See "Treatment, Tests Don't Mean You Can't Code a Consult" on page 91 for more on consultations and treatment.

Alternative: If the visit does not qualify as a consultation, you should report the appropriate new or established patient office visit code (99201-99215).

"There are the patients who are self-referred because of symptoms, and they feel that they need to see a urologist," says Nancy Griffin, MA, CPC, billing manager for five physicians at the Swedish Urology Group in Seattle.

You may also see referrals from the emergency department for patients with acute prostatitis, which again would not be a consultation because of the referral source.

Step 2: Decipher Between Prostatitis and BPH

If you can't tell prostatitis from benign prostatic hyperplasia (BPH), your diagnosis coding will suffer. Home in on your urologist's documentation details to be sure you're coding the correct ailment.

Prostatitis is inflammation of the prostate, whereas BPH is a benign enlargement of the prostate. Treatment for prostatitis consists of an antibiotic, usually Levaquin or Cipro, while BPH treatment includes beta blockers, Proscar, or surgical intervention.

"Some of the presenting complaints are the same with BPH and prostatitis," Young says, and the urologist may not have reached a specific diagnosis at the conclusion of his initial encounter. If you don't have a specific diagnosis from the urologist when you're coding the service, both CMS and CPT rules allow you to associate the patient's signs or symptoms with the CPT codes you report.

The codes: When the urologist provides a definitive diagnosis of prostatitis, report acute prostatitis with 601.0 and chronic prostatitis with 601.1. For unspecified prostatitis, use 601.9, Griffin says. You may report 601.0, 601.1 or 601.9 as the primary diagnosis, with the symptoms--such as frequency (788.4x), urgency (788.31) or dysuria (788.1)--as secondary diagnoses.

Tip: If the physician diagnoses BPH, be sure to report 600.00-600.01 (Hypertrophy [benign] of prostate ...) as your primary diagnosis.

Step 3: Don't Forget the Follow-up Visit

For follow-up visits to check on prostate status, use E/M codes 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...). The tricky part in coding the follow-up visit is choosing the proper diagnosis code.

You should report 601.0 or 601.1 rather than V codes for any prostatitis follow-up visits, experts say. The follow-up visits refer to the ongoing prostatitis management, so you should again be using the prostatitis diagnosis.

The confusion: Coders always face the problem of whether to code for the original diagnosis or the V67.x (Follow-up examination) series. In general, they reason, if the problem was resolved, they should use V codes. If the urologist is still treating the problem, they should code for the illness using the prostatitis diagnosis codes. Young sometimes uses the V codes as a second or third diagnosis.