Urology Coding Alert

Question: A patient was referred to us by his primary- care physician because of concern over raised PSA levels. Following a complete in-office evaluation, no further therapy was recommended and the patient was returned to the PCP for follow-up care. No procedures were performed. How should we code this?
     
Wisconsin Subscriber

Answer: Code it as a consultation. CPT includes four types of consultations: office or other outpatient (99241-99245), initial inpatient (99251-99255), follow-up inpatient (99261-99263), and confirmatory (99271-99275).
 
The first step to using the correct consultation code is identifying the location of the consult, choosing between an office or other outpatient setting (i.e., emergency department, ambulatory facility or rest home) and an inpatient setting (i.e., hospital, nursing facility or partial hospital setting).
 
To code this service as an office consultation, you have to choose a code from the 99241-99245 series, depending on the level of the consult. Because there has been an official request for the consultation, a documented reason for the consultation and a written report sent to the attending the physician, all needed criteria have been met for you to use a consultation code.
 
In the past, some payers have not reimbursed consultation codes if the consulting physician initiated any diagnostic and/or therapeutic services. In 1999, CMS clarified that Medicare will pay for a consult regardless of whether treatment is initiated, as long as all consultation criteria are met and no transfer of care occurs. However, following a consultation, a urologist may indeed make a decision that he will take over the care of the patient. A consultation should still be billed and paid even under this clinical scenario.
 
Confirmatory consultations "initiated by a patient and/or family," according to CPT, are entirely different from their fellow consultation codes. For second opinions, use the confirmatory consult codes.
 
Whenever a carrier or a governmental, legislative or regulatory body requests a confirmatory consultation to determine medical necessity before agreeing to cover a procedure or service, report the appropriate code (99271-99275) appended with modifier -32 (Mandated services).

 - Answers to You Be the Coder and Reader Questions contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook, New York; and Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 19-urologist practice in Indianapolis.