Urology Coding Alert

Question: We have a patient who was last seen by our PA on 10/21/11 for abdominal pain. This patient came back on 1/28/14 and saw the urologist for possible urethral obstruction and other urinary issues. I say that it should be coded as established since it hasn’t been three years since last visit to our office. My doctor thinks it should be a consultation because patient was referred for evaluation of a new problem. Which one is correct and why?

Arkansas Subscriber

Answer: This is an established patient. The patient has seen a provider in the same specialty in the same practice within the past three years.

That said, the consultation codes can be used for new or established patients, if a request has been made by another provider. Codes 99241-99245 are for “Office consultation for a new or established patient, which requires these 3 key components ....” As indicated in the code descriptor, you can use these even if the patient has been seen in the past three years.

Depending on the documentation, the doctor may be correct about billing a consultation. If another provider is seeking your provider’s opinion on the patient’s problem and your provider sends a return report back to the requesting provider giving his opinion and recommendations, then a consultation code may be appropriate.

Know the rules: Make sure you meet all of these requirements before you bill a consult code:

• Another physician or appropriate source must refer the patient. You must document the referring physician’s name in the consultant’s note and his request for a consultation;
• You must document the reason for the patient referral in the consultant’s note;
• You must document the history, exam, and decision making; and
• Your surgeon must provide a written reply to the requesting provider.

If you don’t meet any of these steps, such as a patient who is self-referred or referred by a friend, you should use the new (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient...) or, in this case, established (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient...) patient codes. All of this information is available in the CPT® guidelines to the consultation codes.

Take note: In the past, you needed a written referral before you could bill a consultation, but starting in 2010, you no longer needed a written request from the referring provider. Prior to 2010, Medicare was adamant about the written request requirement. Because Medicare no longer recognizes consultation codes, CPT®’s rules are now definitive for billing consultations.

Be careful: Make sure the payer you are billing to still accepts consultation codes, because some payers, such as Medicare, no longer accept 99241-99245.