Urology Coding Alert

Cut through the confusion with these tips Several managed-care providers and private carriers will not reimburse for vasectomies for elective sterilization. What's a coder to do to get the most from this common elective procedure?
 
The keys are documentation and knowing your carrier's definition of a consult versus a new/established patient visit. Linking Is Critical The ICD-9 Code most appropriate for the prevasectomy examination - whether it's a consultation or a new/established patient visit - is ICD-9 V25.09 (Encounter for contraceptive management; general counseling and advice; other).
 
But you should also link V25.2 (... sterilization) to the vasectomy procedure (55250, Vasectomy, unilateral or bilateral [separate procedure], including postoperative semen examination[s]).
 
Linking the V code to the procedure is critical because it adds specificity, according to Morgan Hause, CCS, CCS-P, coding compliance specialist for Urology of Indiana. "We asked each of our contracted payers about this specifically, and nearly all instructed us to use V25.2 on the office visit as well as the visit for the vasectomy," he says.
 
"The problem," Hause adds, "is that the V code V25.09 can be used to describe a variety of reasons for care related to contraception management."
 
So for plans that specifically allow for vasectomies, payers cannot discern if V25.09 is intended for a prevasectomy visit and consequently deny it, he says.
 
In the past, many carriers did not pay for vasectomies, treating them as elective procedures, but don't presume that is still the case.
 
"Many payers (and in some cases state law requires coverage) will now pay for vasectomies but might not pay for things such as family-planning sessions, which is why we get denials for clarification," Hause says. Check with your providers to see if they want you to use V25.2 on these office visits and vasectomies.
 
Alice Kater, CPC, of Urology Associates of South Bend in Indiana, offers a variation on this method. She uses CPT 99202 (Office or other outpatient visit for the E/M of a new patient ...) for the E/M encounter (vasectomy consult) and V25.2 as the diagnosis.
 
"We are in Indiana and have had no problems with reimbursement," Kater says, "and we do see quite a bit of BCBS of Michigan since we are just over the state line."

Know the Criteria for a Consult Much of the confusion begins with the question: Is it a consult or a new patient visit?
 
Should urologists treat initial patient visits for the vasectomy consult as a true consult as defined by Medicare or should they bill it as a new patient visit?
 
Like many coding issues, the answer is not black and white. But there are criteria you can use to determine the correct code. At issue is the slightly higher reimbursement assigned [...]