Urology Coding Alert

Question: I know that a nonphysician practitioner and a urologist can "share" an E/M visit, for instance, a physician assistant or a nurse practitioner may take the history and perform some preliminary work and then hand off the patient to the urologist for the exam. Although I have not seen anything in writing, I have heard that this practice is unacceptable for consultation services. Is this true?


New Jersey Subscriber

Answer: Coding experts and CMS regulations agree: You cannot bill consults as "shared visits" with nonphysician practitioners.

Specifically, the CMS definition of a shared visit says the service must follow all the rules of an "incident-to" office service--which means that there should be an established patient with an established problem and care plan. And, generally, these aren't the circumstances with a consult.

Regardless of the patient's status, however, when a requesting physician asks for a consult, he is only seeking your urologist's opinion, not the opinion of other providers in your office.

Clarification: Recently, CMS clarified this. Unless the requesting provider directs the consultation request at a particular person in the practice, anyone able to provide the consultation (urologist, PA, NP, etc.) can see the patient and respond to a generalized consultation request. But you can't have a shared in-office or in-hospital consultation.

Bottom line: Consults are already an area under intense scrutiny by payers and the HHS Office of Inspector General, and you shouldn't place your claims in jeopardy by violating "shared visit" criteria. Best practice and ethical considerations dictate that the consulting physician should provide the entire service if he wishes to report a consultation. He should not rely on the work or opinions of nonphysician practitioners (who may not meet carrier requirements of a consultation service) when reporting either outpatient (99241-99245) or inpatient (99251-99255) consultations.