Urology Coding Alert

Question: When a patient is admitted to the hospital for a non-urology problem (fractured tibia/fibula) and the urologist visits the patient to monitor a pre-existing problem (UTI, ESRD), should a consultation code be used?

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Answer: You would use a consultation code (99251-99255) for the inpatient visit if the orthopedist, or the patients primary care physician, requested a consultation for your opinion or advice. For example, if the attending orthopedist suspected urinary retention and the patient reported that he had a UTI prior to the injury, the orthopedist may request your opinion or advice on how to manage this condition. Code the consultation with the retention diagnosis (788.20). If the patient has ESRD, and the orthopedist requests a consultation, code the visit with the ESRD diagnosis (585). Use the fracture diagnosis in the secondary position.
 
Document the request for a consultation and also send a written opinion to the requesting physician. If the orthopedist did not request a consultation, but the patient or family called you to say the patient could not keep the appointment and you visit the patient, you would code the subsequent visit with 99231-99233.
 
Answers to Reader Questions and You Be the Coder provided by Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services in Denver; and Michael A. Ferragamo, MD, professor of urology at State University of New York, Stony Brook.