Urology Coding Alert

Question: A patient came to the office to see the physician, and the patient refused to fill out a history form, but he brought his records from another physician. The other physician was a urologist who requested a second opinion for this patient. Our physician sent a letter to the referring physician and wants to base the coding on time. The patient did not want to be examined, and the physician was unable to obtain a social/family history, review of symptoms, or a history of the present illness. The physician wants to report a consultation code. Is this the correct way to report this service?

Washington Subscriber

Answer: If the other physician sent the patient for a second opinion, with a request for advice and the opinion from your physician -- the consulting urologist -- you should certainly consider reporting this as a consultation (99241-99245, Office consultation for a new or established patient ...).

The key: To bill a consultation on time alone, however, there still must be a face-to-face encounter between the patient and the consulting physician. If the urologist reviewed the medical records with the patient and then gave the patient his opinion gained from this review, you can count the service as a consultation. In this scenario, without a face-to-face encounter you shouldn't report a consultation code just for a review of the medical records alone.

Tip: To ensure payment for this sort of counseling-dominated visit, your urologist should note the total time spent and the counseling time. Don't forget to document the:

Easy ways to document time visits include:

In addition: Your urologist must send a letter explaining the encounter with the patient and his opinion to the requesting physician to fulfill all the requirements for a consultation.