Urology Coding Alert

Question: I know that CPT Codes deleted the confirmatory consult codes for billing second opinions, but I’m not sure how we should report these services now. Would you advise me how I should report our urologist’s work performing a second opinion?

Illinois Subscriber

 Answer: If a patient presents to your practice requesting a second opinion, you should report the appropriate E/M code (99201-99205 for new patients or 99212-99215 for established patients). Because most second-opinion requests are patient-generated, you should treat these office visits as you would any other E/M visit.

Caveat: In some rare cases, you may encounter a physician-generated second-opinion request that can qualify as a true consultation. According to CMS Transmittal 788, dated Dec. 20, 2005, “In a facility setting, a second-opinion consultation arranged through the attending physician shall be reported by a physician/qualified NPP using an appropriate inpatient consultation code [99251-99255] when the consultation requirements are met. When consultation requirements are not met, the subsequent hospital care codes (99231-99233) in the hospital setting and the subsequent nursing facility care codes (99307-99310) in the NF setting shall be reported.”
 
Remember, however, that if the second-opinion in-hospital consultation follows an initial in-patient consultation from another urologist during the same admission, Medicare will not reimburse for this second in-hospital consultation. Medicare will pay for only one consultation per specialist, per patient, per hospital admission. Many commercial and private carriers may also follow this same policy.
 
However, if you can prove that a physician-generated second opinion is an actual consultation, you should still bill the consult codes -- but again only if the urologist’s documentation supports this.

 -- Answers to Reader Questions and You Be the Coder contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook; and Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist practice in Indianapolis.