Urology Coding Alert

Question: What E/M level should we bill for new vasectomy patients in clinic? A couple of my urology providers think a level 3 or 4 code is customarily billed in private practice. Usually we find that there is a very limited history of the present illness (HPI) documented for this type of discussion, so it is difficult to meet higher than a 2 in my opinion, unless the billing is based on time. Can I ask what bumps this to the level of moderate medical decision making?

New Jersey Subscriber

Answer: A vasectomy carries a 90-day global period; Medicare considers procedures with a 90-day global period a “major” surgery. There is always a risk of infection, failure for sterility, chronic testicular pain, or liability issues. When referencing the Table of Risk, these factors combine to constitute a moderate-level risk.

Fertility in this situation is a “problem” since the patient does not want to have any other children and is seeking medical intervention. This is a new problem since the patient has not seen your physician before, and the situation requires additional work-up (the vasectomy procedure). Combining these factors brings you to moderate complexity medical decision-making (MDM), which can support a level-four E/M code, such as 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity …) if you also have a detailed history or detailed exam.

You are correct that in this scenario the HPI is often deficient to bill a level-four E/M code. For a level-four service for a new patient (99204), you need a comprehensive history. For an established patient (99214), you need a detailed history. To reach detailed or comprehensive history levels, the provider must document four points of HPI.

For example, your urologist could address these four questions:

• How long are you married? (duration)
• How many children do you have? (severity)
• What precautions have you used in the past to prevent pregnancy? (modifying factors)
• Do you suffer from erectile dysfunction? (associated signs or symptoms).

Using these four questions will give you four elements toward an extended HPI. If the provider also reviews at least two systems in review of systems (ROS) and one area of past medical, family, or social history (PFSH), you’ll have a detailed history. Performing a complete ROS and PMSH leads to a comprehensive history.