Urology Coding Alert

Although urologists frequently provide consultations, properly reporting these E/M services remains a persistent coding challenge. Documentation is key, especially now that the Office of Inspector General has listed consultations as one of the investigative focus areas of 2003.

Consultation codes pay better than most office visit (E/M) codes incentive for urology coders to learn how to use them appropriately. As with E/M services, Urology coders should choose the level of consult codes according to the three elements of history, examination and medical decision-making. But to bill consults, physicians must also meet other important criteria that are not clearly delineated. And if consultations are not properly documented, payers may confuse them with referrals or transfers of care, a road that leads straight to denials.

CPT includes four types of consultations: office or other outpatient (99241-99245), initial inpatient (99251-99255), follow-up inpatient (99261-99263), and confirmatory (99271-99275).

The first step to using the correct consultation code is identifying the location of the consult, choosing between an office or other outpatient setting (i.e., ER, ambulatory facility or rest home) and an inpatient setting (i.e., hospital, nursing facility or partial hospital setting).

Suppose a 70-year-old male patient is sent by his primary-care physician (PCP) to a urologist for his opinion and advice concerning a slightly elevated prostate-specific antigen (PSA) level. Following a complete evaluation, no further therapy is recommended and the patient is returned to the PCP for follow-up care.

To code this service as an office consultation, you have to choose a code from the 99241-99245 series, depending on the level of the consult. Because there has been an official request for the consultation, a documented reason for the consultations and a written report sent to the attending the physician, all needed criteria have been met for use of a consultation code.

The outpatient consultations codes do not have outlined restrictions on their frequency of use, and it is not necessary for the patient to present with a new problem for an additional consultation code to be appropriate, according to the CPT 2002 guidelines. Typically, when a patient returns for an additional consultation, the patient has a problem unrelated to the original complaint or has a progression of the original problem, says Jennifer C. Simpson, CPC, a practicing coder in Lexington, Ky. If an additional consultation is required for a given patient, be sure to include a detailed explanation for the subsequent consultation(s).

For example, when a repeat PSA determination for the above patient later indicates a markedly increased level, the PCP requests another opinion from the same urologist as to further management. This second visit to the urologist is considered another consultation, and if the service is provided in the office or outpatient facility, choose a code from the range 99241-99245.

In another example, a urologist sees an established 65-year-old male patient in follow-up for an enlarged prostate gland, ICD-9 code 600.0, on Monday morning. The urologist renews his medication, warranting office visit code 99213. Later that same week, the patient visits his PCP complaining of flank pain. Uncertain of the diagnosis, the PCP requests an opinion from the patient's urologist.

This second visit to the urologist satisfies the criteria for another consultation and merits a code from range 99241-99245. In this case, the diagnosis is renal colic, 788.0. Note that CPT does not provide outpatient or office visit follow-up consultation codes as is does for inpatient follow-up consultations, so you must use a code from the same range as the initial outpatient consultation code, 99241-99245.

Coders beware: These outpatient consultation codes, unlike the office visit codes 99201-99215, are not subdivided into new patient and established patient classifications, says Tracy Moore, CPC, a coder with Gaston Urological Associates in Gastonia, N.C. In fact, the definitions of these codes require that all three components of history, examination and medical decision-making be met before a level of consult can be assigned, regardless of whether the patient is new or established.

Satisfying all three components before assigning both new and established outpatient consultation levels also applies to inpatient consultations, Moore says, but only the initial, or first, consultation provided by a physician to a patient.

Note the CPT guidelines that instruct coders to use only one of the initial inpatient consultation codes, 99251-99255, per patient admission. These guidelines direct you to use the follow-up inpatient consultations for any subsequent consultations requested by the attending physician and provided during the same patient admission.

The follow-up codes, 99261-99263, are used when the physician who conducted an initial in-hospital consultation performs a second in-hospital consultation at the request of the consulting physician to recommend further management modifications, for example. This follow-up consultation is considered an "established patient" follow-up inpatient consultation. The guidelines for these procedures indicate that only two out of the three components history, examination and medical decision-making need to be met to determine the level of consultation.

In another example, a urologist who works in a private practice is called to the hospital to evaluate a patient undergoing a sling procedure for urinary incontinence. The attending physician seeks the consulting physician's advice on whether the patient has a laceration of the ureter. The consulting physician evaluates the patient and refutes the presence of a laceration. After the attending physician completes the sling procedure, he requests that the private-practice physician advise on the management of the patient during the immediate in-patient postoperative period. Under these circumstances the follow-up consultation codes are required.

"If a patient is admitted to the hospital and has a consultation, and the patient is discharged from the hospital, readmitted and has a second consultation for the same problem as the previous consultation, you use the initial hospital consultation codes," says Kimberly Hodges, CPC, coding specialist for Guerrero & Salib, MDs, in Titusville, Fla. But if the patient has not been discharged from the hospital and requires a second consultation, even if it is for the same or a new problem, a follow-up consultation code is required regardless of the diagnosis.

In the past, some payers have not reimbursed consultation codes if the consulting physician initiated any diagnostic and/or therapeutic services, such as writing orders or prescriptions and initiating treatment plans. But in July 1999, CMS transmittal R1644.B3 (effective Aug. 26, 1999) clarified that Medicare will pay for a consult regardless of whether treatment is initiated, as long as all consultation criteria are met and no transfer of care occurs, says Sharon Tucker, CPC, president of Seminars Plus, a consulting firm specializing in coding, documentation and compliance issues, in Fountain Valley, Calif.

The MCM, section 15506, further explains, "A transfer of care occurs when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance." "Referral," in this instance, is simply another term for transfer of care.

Although the terms "referral" or "consult and treat" do not specifically denote a transfer of care, physicians should avoid these terms when requesting or describing a consultation, Tucker says. Auditors and payers may automatically consider "referral" or "consult and treat" to mean that the physician to whom the patient is presenting for an opinion or advice is assuming the patient's complete care, and therefore may not reimburse for a legitimate consultation.

When documenting your written consultation report, indicate that the encounter was a consultation in addition to the reason(s) for the consultation. Use sentences and words such as "I am pleased to send you a report on Mrs. Jones, who was recently in my office for a urological consultation at your request" and "for stress incontinence of three years' duration," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook, New York. It is also a good idea to end your letter with the following: "Thank you for the courtesy of this consultation."

The use of such phrases as noted above and the avoidance of the words "referring" and "referral" will give strong evidence to any auditor that a consultation was in fact performed.

Confirmatory consultations consultations "initiated by a patient and/or family, and not requested by a physician," according to CPT are entirely different from their fellow consultation codes. "For second opinions, use the confirmatory consult codes," Hodges says.

Anytime it is an insurer, a PRO, or a governmental, legislative or regulatory body requesting a confirmatory consultation by a specialist to determine medical necessity before agreeing to cover a procedure or service, report the appropriate code (99271-99275) appended with modifier -32 (Mandated services) or you can expect the claim to be questioned.

For instance, suppose the patient's insurer seeks a second opinion from another urologist before approving coverage for prostatic surgery. This second urologist evaluates the patient in the hospital at the insurer's request and performs the necessary diagnostic tests to confirm or disprove medical necessity for the surgery. The session is coded 9927x for the consultation, depending on the documentation, with modifier -32 appended. Code any testing service performed in addition to the consultation.