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. Locate Correct Consultation Codes First 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 [...]
