Urology Coding Alert

Reader Question:

Collaborate on In-Office Referral Documentation

Question: For a patient interested in a minimally invasive procedure for BPH, one of our physicians requested a consultation from his partner with expertise in the TUNA procedure. What chart documentation needs to be present to report a consultation code considering the doctors are partners and they are sharing the chart? Is a letter from the referring physician still required?

Indiana Subscriber
 
Answer: Before you decide how to report this service, you must decide whether the first urologist has truly requested a consultation and opinion from his partner.  If so, and the doctor specifically asked the transurethral needle ablation (TUNA) specialist for his opinion, this fact must be in the patient's chart to satisfy the "request for consultation" requirement. Separate letters from the requesting and consulting physicians are not needed because both are using a common chart.
 
However, if one of your doctors is referring the patient to his partner because only he performs the TUNA procedures, you should not report a consultation code.

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