Urology Coding Alert

Most urologists consider a prevasectomy visit a consultation (99241-99245). But most coders do not, arguing that they are a new patient visit (99201-99205) or if you have seen the patient before an established patient visit (99212-99215). Consultations carry significantly more relative value units (RVUs) than patient office visits, so proper coding clearly affects the practice's bottom line.

Frequently, a patient, at the request of his primary care physician (PCP), presents to the urologist for advice and an opinion concerning a vasectomy (55250, Vasectomy, unilateral or bilateral [separate procedure], including postoperative semen examination[s]). Most commonly, the patient indicates to the PCP that he is interested in a vasectomy and wants more information. The PCP usually writes in his record, "To urologist for vasectomy," and this is where the problem begins for the urologist. The PCP's statement does not completely describe the nature of the patient's request, which is not necessarily for a vasectomy but for more information.

This initial visit to the urologist includes an explanation and counseling session, as well as a physical examination. The urologist uses the history and examination to determine the patient's suitability for a vasectomy and to uncover any emotional or physical contraindications to the surgery. A decision by the patient to undergo the procedure is frequently made during this visit. The urologist also usually sends a letter of recommendations to the requesting PCP regarding the patient's care. Consequently, most urologists consider this scenario a consultation because it fulfills Medicare's requirement of the "three R's": request for opinion, rendering of services (an exam) and reporting back to the requesting physician.

If the patient seeks out the urologist for a vasectomy, without a referral from a physician, this E/M visit should be coded as a new patient visit (99201-99205), unless the urologist has seen the patient within the past three years, in which case you should report an established patient visit (99211-99215). No consultation letter to the patient's PCP is required.

Also, you should not bill a consultation if the referring physician has already provided the necessary procedure explanation to the patient and he decided then to undergo the vasectomy. In that case, the urologist would perform the vasectomy the same day the patient is first seen, billing 55250 and adding modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or modifier -57 (Decision for surgery) to the office visit (99201-99215), depending on the insurance carrier's requirements.

Under the above rare conditions, the patient has already decided to have the surgery, and the referral to the urologist is primarily used to arrange for the procedure. Although the urologist will re-examine the patient's understanding of the procedure and perform a physical exam, you should not code for a consultation.

A letter from the urologist to the PCP, although informative, does not necessarily constitute or change an encounter to a consultation. Whether the visit is a consultation depends on the services the urologist performs.

"Be careful you're not doing a report just so you can bill a consult code," warns Joan Gilhooly, CPC, CHCC, president of Medical Business Resources, a coding, compliance and reimbursement consultancy based in Chicago. A consultation code is inappropriate for an initial vasectomy visit, says Gilhooly, who questions whether the PCP is seeking the urologist's opinion and advice.

"For a visit to be billed as a consultation, everyone's documentation has to match," she says. When the requesting physician gets the preauthorization for the referral, the PCP must state that he or she is seeking the urologist's advice and opinion regarding whether the patient is a good candidate for surgery.

"It's not so much whether a report or letter is sent back to the PCP, but exactly whom the advice and opinion is being provided to," Gilhooly says. "There's no doubt that the urologist is doing an evaluation of the patient's appropriateness for any kind of intervention. But the urologist would do this evaluation even if the patient had no referral."

The biggest difference in the RVUs for a level-three office visit and a level-three consultation is practice expense because the consultation requires the letter to the referring physician. "So consider whether the letter is needed or is just a courtesy," says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer based in North Augusta, S.C. Many physicians write the letter thanking a colleague for a referral without billing a consultation code.

From a medical care perspective, the letter to the PCP from the urologist is not necessarily required in the case of a vasectomy, Gilhooly says. If a patient complained of urinary frequency to his PCP, and the PCP referred the patient to a urologist, that would clearly be a consultation, Gilhooly says, because the PCP does not know the cause of the frequency. But in the case of a vasectomy, the PCP knows the problem the patient does not want more children and the treatment.

The point of a consultation for CPT coding purposes is that the specialist is being asked to render advice and/ or an opinion. The PCP's chart will state that the patient was referred to the urologist for a vasectomy. It will not state that the patient was referred for a problem that has an as-yet unknown treatment that requires the urologist's advice or opinion.

If you want to bill a consultation code, educate referring physicians. Provide them with a form that shows they are clearly requesting evaluation and treatment.Note: Interestingly, if a psychological or physical problem contraindicates a vasectomy and the urologist conveys these findings and opinion to the PCP, few coders would disagree with reporting a consultation code. Why, then, would there be a question as to whether a consultation should be billed if the urologist goes on to perform the vasectomy? "Because the PCP is not asking the urologist for advice, he's transferring the patient for care for that problem," Callaway says. "The PCP is not asking, 'Is this an appropriate candidate for surgery?' " she adds. "That's always the surgeon's responsibility consultation or not."

The ICD-9 code most appropriate for the prevasectomy examination whether 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 (55250). Unfortunately, some carrier software is programmed to accept only V25.2 for any services concerning male infertility. Ask your carrier which V codes it requires for payment and be sure to get the requirements in writing in case you need to support your coding decisions later.