Urology Coding Alert

Brush up on the difference to stay away from audits - and save $45

Just because another physician "refers" a patient to your urologist doesn't mean you should assume the visit is a referral or transfer of care - that is, unless the patient meets this expert criteria. "Doctors frequently say to patients, 'I'm going to refer you to a specialist to see exactly what your problem is.' But they aren't clear when they say the word 'refer,' and this can spell trouble for coders trying to choose a correct E/M service code," says Marvel Hammer, RN, CPC, CHCO, a consultant with MJH Consulting in Denver.

Let the "Three R's" Guide You: Likewise, if the urologist says he "consulted" with the patient, you shouldn't automatically choose a consult code. A "consult" as defined by CPT describes a very specific service that involves three components:

 A request from another physician for a consult

 An opinion rendered by the consulting physician

 A report on the patient's condition sent by the consulting physician to the requesting physician (most often in the form of a consultation letter).

Using these three criteria, you can separate the consults from the transfers of care.

Self-Referrals and Recommendations Don't Count

If a patient visits your urologist on his own accord, or at the "recommendation" of another physician, you must select a standard outpatient E/M code (99201-99205 for new patients, or 99211-99215 for established patients) to report the service.

"The patient may have a recommendation from the attending doctor to see a physician in a particular specialty group," says Cindy Parman, CPC, CPC-H, RCC, principal of Coding Strategies Inc. in Powder Springs, Ga., but you cannot bill for a consult if "the attending physician did not specifically ask for an opinion or advice from the specialist." This request from the attending physician must be recorded and available as a part of the patient's medical record.

'Some Care' Doesn't Mean 'Transfer of Care'

You may report a consult even if your surgeon schedules testing or initiates care for the patient - if the visit meets the requirements of request, render and report.

CPT Codes 2004 makes this point clearly, stating, "A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit."

And, in July 1999, CMS transmittal R1644.B3 (effective Aug. 26, 1999) clarified that Medicare will pay for a consult regardless if the consulting physician initiates treatment, as long as all consultation criteria are met and no transfer of care occurs.

Many insurance companies that see a consult code alongside a treatment or procedure will automatically downcode the claim to a new patient visit. You should appeal these claims if you have proof that there was no intent to transfer care on that visit, Hammer says.

Urology example: A primary-care physician requests that your urologist provide a consultation for a patient complaining of erectile dysfunction. The urologist meets with the patient, performs a blood test and urine analysis and spends some time with the patient discussing possible diagnoses and treatment options. The urologist prepares a report of his findings and sends them to the requesting physician, then recommends that the patient return soon for penile blood-flow analysis.

In this case, even though the urologist provided testing and recommended potential treatment options, you may still report a consult: No transfer of care has occurred at this point, and the surgeon has met the requirements of request, render and report.

If Physician Takes Over Care, Use Outpatient E/M

If, after an initial consultation, the consulting physician accepts primary care for the patient's condition, you must report all subsequent visits using the appropriate-level outpatient E/M code, says Wanda Starnes, CPC, coding specialist at the Urology Center of Spartanburg in South Carolina.

"A transfer of care occurs when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance," according to the Medicare Carriers Manual, section 15506.

"In this case the urologist accepts the patient for complete urological care before and in advance of seeing the patient," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York in Stony Brook. "In my experience, this does not happen very often. Therefore, when a patient is sent to the urologist by another physician for an opinion, this represents a consultation more often than not, especially if the 'Three R's' criteria for a consultation are met."

Urology example: Returning to the above case: After the initial consultation, the urologist accepts responsibility for diagnosing and treating the patient's erectile dysfunction. On subsequent visits, the urologist will report established patient office visits (99211-99215), as well as any testing or treatment codes supported by documentation.