Urology Coding Alert

Most urologists consider a prevasectomy visit a consultation (99241-99245). But most coders do not, arguing that they are a new patient visit (99201-99205) or if you have seen the patient before an established patient visit (99212-99215). Consultations carry significantly more relative value units (RVUs) than patient office visits, so proper coding clearly affects the practice's bottom line.

Frequently, a patient, at the request of his primary care physician (PCP), presents to the urologist for advice and an opinion concerning a vasectomy (55250, Vasectomy, unilateral or bilateral [separate procedure], including postoperative semen examination[s]). Most commonly, the patient indicates to the PCP that he is interested in a vasectomy and wants more information. The PCP usually writes in his record, "To urologist for vasectomy," and this is where the problem begins for the urologist. The PCP's statement does not completely describe the nature of the patient's request, which is not necessarily for a vasectomy but for more information. This initial visit to the urologist includes an explanation and counseling session, as well as a physical examination. The urologist uses the history and examination to determine the patient's suitability for a vasectomy and to uncover any emotional or physical contraindications to the surgery. A decision by the patient to undergo the procedure is frequently made during this visit. The urologist also usually sends a letter of recommendations to the requesting PCP regarding the patient's care. Consequently, most urologists consider this scenario a consultation because it fulfills Medicare's requirement of the "three R's": request for opinion, rendering of services (an exam) and reporting back to the requesting physician. When the Visit Is Not a Consultation If the patient seeks out the urologist for a vasectomy, without a referral from a physician, this E/M visit should be coded as a new patient visit (99201-99205), unless the urologist has seen the patient within the past three years, in which case you should report an established patient visit (99211-99215). No consultation letter to the patient's PCP is required. Also, you should not bill a consultation if the referring physician has already provided the necessary procedure explanation to the patient and he decided then to undergo the vasectomy. In that case, the urologist would perform the vasectomy the same day the patient is first seen, billing 55250 and adding modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or modifier -57 (Decision for surgery) to the office visit (99201-99215), depending on the insurance carrier's requirements.

Under the above rare conditions, the patient has already decided to have the surgery, and the referral to the urologist is primarily used to arrange for the procedure. Although the [...]