Urology Coding Alert

Question: If a patient is referred to me by an emergency room physician, can I bill for a consultation?

Anonymous Arkansas Subscriber

Answer: It depends on whether the ER doctor wants your opinion or is transferring the patient to you for care. If, for example, the patient is being referred for retention of urine, this is a transfer of care. The ER doctor is not asking you for an opinionyoure being asked to take over the patients case. You must bill a new patient code (99201-99205).

If, however, the patient is being referred to the urologist for lower back pain due to suspected kidney stones, then, when you arrive, you must conduct your own history, exam and medical decision-making to determine the diagnosis of a kidney stone (592.0) and the best course of treatment. As the urologist, you can immediately begin workup and treatment and still charge a consultation code (99241-99275).

The issue is intent. And intent is derived from the requesting physicians note. If the note says, Patient with kidney stones. Called in a urologist, this is a transfer of care and a new patient. If the note says, Patient with lower back pain. Called in urologist for opinion on possible kidney stones, this is a consultation request.

Experts recommend that urologists spend some time discussing the format of ER requests because this can be a big problem. Remember that you can bill a consultation only provided that you follow the rules for consultations.

Here are the rules: (1) The urologist must be requested by another physician to provide an opinion or advice regarding evaluation and/or management of a specific problem; (2) The need for the consultation must be documented; and (3) The urologist must write a report for the requesting physician.
There may still be some confusion over whether a urologist can bill a consultation and go on to treat the patient. Last year, the Medicare consultation guidelines were clarified to make it clear that a doctor can bill a consultation and go on to treat the patient, providing the three above criteria are met. According to transmittal 1644, a revision to section 15506 of the Medicare Carriers Manual, carriers must pay for a consultation regardless of treatment initiation unless a transfer of care occurs.

This means that the urologist who sees a patient when the ER doctor refers for kidney stones, performs subsequent testing, and then returns the patient to the primary-care physician for general care, can bill a consultation for the first visit. Its important to remember that under the rules of last years transmittal, you no longer need a written request for a consultation. All you need to do is document in the patients medical record that a request was made.

Tip: If the patient is discharged from the ER, use the outpatient consultation codes (99241-99245). If the patient is admitted to the hospital for treatment, use the initial inpatient consultation codes (99251-99255) with a -25 or -57 modifier.

Sources for answers to You Be the Coder and Reader Questions: Ruth Borrero, assistant billing manager specializing in Medicare reimbursements, Urology Associates, Manhasset, N.Y; Caroline Warfield, billing manager, Associated Urologic Specialists, Marlton, N.J; Thomas A. Kent, CMM, president, Kent Medical Management, Dunkirk, Md.; Catherine Brink, CMM, CPC, president, Healthcare Resource Management Inc., Spring Lake, N.J.