Urology Coding Alert

Prostatitis implies inflammation of the prostate, which may be acute (601.0) or chronic (601.1). There is a range of diagnostic and treatment options that the urologist needs to consider. Well take you through the coding process, from the initial visit to the treatment and follow up.

Initial Visit: Consultation

The first visit for acute prostatitis is usually a consultation (99241-99245). The primary care provider may have requested the consultation because the patient had symptoms such as frequency, urgency or dysuria, and the prostate is enlarged and/or extremely tender. The diagnosis codes on the consultation would be the prostatitis first, if that is what the physician finds, with the symptoms such as frequency (788.4x), urgency (788.31) or dysuria (788.1) as secondary diagnoses.

Medicare has three requirements for a consultation:

1. The consultation must be provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other source who is paid by Medicare, such as a physicians assistant, nurse practitioner, podiatrist or chiropractor;

2. The request and reason for the consultation must be documented; and

3. The consultant must prepare a written report regarding his or her findings and treatment suggestions for the referring physician.

In a typical case of prostatitis, if a primary care provider refers the patient to a urologist, the urologist must document the request and write a letter to the referring physician reporting his or her findings.

Last year, Medicare clarified that a physician may treat a patient and also charge a consultation for the first visit. According to transmittal 1644 of the Medicare Carriers Manual, physicians can provide treatment after a consultation as long as there is no transfer of care. The transmittal directs carriers to pay for a consultation regardless of treatment initiation unless a transfer of care occurs, as long as the above three criteria are met.

From the transmittal: A transfer of care occurs when the referring physician transfers the responsibility for the patients complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance. If there is a transfer of care, depending on the situation, the receiving physician must report a new or established patient visit (99201-99215), and a consultation cannot be billed.

BPH vs. Prostatitis

Urologists should note that prostatitis is not the same as benign prostatic hyperplasia (BPH) (600.0), which is a benign enlargement of the prostate. Treatment for prostatitis consists of an antibiotic, usually Levaquin or Cipro, while treatment for BPH consists of beta blockers and/or Proscar, which are payable with the diagnosis code 600.0, according to Michael Ferragamo, MD, FACS, a urology coding consultant with PRS, a coding and reimbursement consulting firm based in Denver. For Lupron and Zoladex, anti-cancer drugs used at times for the treatment of BPH symptoms, payment is often denied because some states will allow payment for these medications only with a carcinoma diagnosis (e.g., 185).

Follow-up Visits

For follow-up visits to check on the status of the prostate, use evaluation and management (E/M) codes 99212-99215. However, the question of diagnosis codes is tricky. I would use 601.1, 601.0 or 600.0 rather than V codes for follow-up visits, Ferragamo says.

Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding, compliance and reimbursement consulting firm based in Denver, agrees. The follow-up visits refer to the ongoing management of the prostatitis, she says. Therefore, prostatitis diagnoses should be used.

The V67 series of the follow-up diagnosis codes usually is not payable. Coders always face the problem of whether to code for the original diagnosis or the V67 series. In general, they reason, if the problem was resolved, V codes should be used. If the problem is still being resolved, they should code for the illness.

From a clinical viewpoint, however, Ferragamo believes that the V codes are never appropriate. One is never sure that the disease process is completely resolved, he says. I suggest using the illness codes exclusively for the follow up until completion of all therapy.