Urology Coding Alert

Follow these expert guidelines to get your share of high-paying E/M services The urologist is called to the emergency department to consult on a patient's diagnosis and concludes that the patient is well enough to go home. You report consultation code 99251, but all you get is denied.

To avoid denials like these, you need to know CPT's criteria for a consult. If the consultation a urologist performs doesn't meet the criteria of the consult you report, you could be receiving reduced reimbursement, or worse, outright denials.

Our experts explain how the critical "Three R's" and differentiation between inpatient consultations and follow-up consultations can make or break your consultation reimbursement.

The first step to determining which type of consult code to report is knowing where the urologist was. Just like the office visit E/M codes (CPT 99201 -CPT 99215 ), the level of consult code you choose within each type depends on satisfying a certain number of key components in the history, examination, and medical decision-making. Office or Outpatient Consultations Report 99241-99245 (Office consultation for a new or established patient ...) for consultations in the office, in the ED when the patient is not admitted, or in the outpatient department of the hospital.

Example: An emergency department physician calls the urologist to consult on the diagnosis of a patient who has abdominal and flank pain. The urologist diagnoses renal colic (788.0) and advises that the patient is doing well enough to go home. Report the appropriate level of office or outpatient consultation code (99241-99245). Inpatient Consultations Submit codes 99251-99255 (Initial inpatient consultation for a new or established patient ...) for consultations regarding patients in hospitals, nursing homes, or skilled nursing facilities.

Example: The urologist is called to the ED in consultation for a patient with abdominal and flank pain, along with a low-grade fever. The urologist diagnoses renal colic (788.0), and recommends that the patient be admitted to the hospital because of the fever and a need for IV fluids. Report 99251-99255 for the urologist's first hospital visit, with the emergency physician as the requesting physician. Report subsequent hospital care with 99231-99233. Follow-Up Consultations Report codes 99261-99263 (Follow-up inpatient consultation for an established patient...) for follow-up inpatient consultations.

Example: The urologist performs a consultation in the hospital. Later, during that same patient's hospital stay, the requesting physician calls the urologist back for further advice concerning a change in treatment. Report 99261-99263 for this follow-up in-hospital consultation.

However: In these cases, urologists often use the higher-paying codes 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) because it is difficult to determine if a second visit with a patient actually qualifies as a follow-up consultation, says Michael A. Ferragamo, [...]