Urology Coding Alert

When a urologist visits the emergency department (ED), coders are faced with a wide variety of codes to choose from. There are many different alternatives, and urology coders must choose the right code depending on the circumstances to receive optimal reimbursement and to avoid fraud.

The following details some of the circumstances that may be involved when a urologist is called to the ED:

1. Consultation: If the ED physician has already seen the patient and requests that the urologist see the patient, the urologist may bill an outpatient consultation (99241-99245), says Elaine Bloom, account representative for State College Urologic Associates, a three-urologist practice in State College, Pa. The requirements for a consultation must be followed: The ED physician must be soliciting the urologists opinion or advice (not simply transferring care), the urologist must document the request and reason for the consultation, and he or she must prepare a written report for the ED physician. It doesnt matter whether the patient is new or established. A typical example of an ED consultation for a urologist is when a patient complains of abdominal and flank pain and the emergency room physician asks the urologists opinion about whether it is renal colic.

Note: If the patient is discharged from the ED, use the outpatient consultation codes.

2. Emergency services visit: Sometimes, the patient shows up in the ED, and the ED physician doesnt see the patient. Instead, the urologist is called right away. In that case, the urologist should bill an ED services code (99281-99285) or a new patient code (99201-99205). You have to be careful not to bill an emergency code if the emergency room doctor saw the patient, Bloom says. If that happens, then the emergency room doctor wont get paid. Note that Medicare will pay for two emergency department codes, and some private payers will as well.

In fact, in this scenario, the emergency room physician usually doesnt see the patient at all, explains Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York, Health Science Center in Stony Brook. The nurse in the emergency room does the triage, and she calls the urologist because she knows this is a urology patient, Ferragamo says.

The encounter in the emergency department does not have to be an emergency in order to bill emergency services, Ferragamo says. You may just be in that location for your convenience or the convenience of your patient. Sometimes the problem occurs on a weekend, and its easier for doctor and patient to get to the emergency department of the hospital than it is for them to get to the office. Some payers, however, have limitations on paying for emergency department services without an emergency diagnosis.

When an emergency department physician sends a patient to a urologists office, the office should bill an outpatient services code (99201-99215), not a consultation, because the patient was sent for care, not for an opinion or advice. In addition, the patient is rarely sent back to the emergency department for followup care (a return to the requesting doctor). But, when the emergency department physician asks the urologist to take over the care of the patient in the emergency department (such as for urinary retention after a Foley catheter has been passed by the emergency department physician), coders should bill for a new patient visit or use an emergency department code. If the patient has been seen by the urologist within the past three years, coders cannot bill for a new patient visit. (Reminder: If the emergency department physician is billing for his or her service, the urologist should not use emergency department codes.)

3. Hospital admission: If the urologist admits the patient to the hospital from the emergency department, use a hospital admission code (99221-99223) or an inpatient consultation code (99251-99255). No matter how much work he or she does in the emergency department, the urologist can only bill for the admission, Bloom says, noting that only one evaluation and management (E/M) service can be billed per day. However, the urologist can code a higher-level hospital admission based on the work he or she did in the emergency department.

Use the consultation codes when the emergency department physician calls in the urologist for an opinion and advice. Use the emergency physician as the requesting doctor in the documentation, Ferragamo says. If the requirements of a consultation are not met opinion and advice solicited, request documented and report to the requester written you cannot bill a consultation, just the hospital admission.

4. Immediate surgery: If the urologist determines that surgery will have to be done that day or the next, a -57 (decision for surgery) or -25 modifier (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) must be appended to the E/M services code, regardless of the code used consultation, emergency or admission. The modifier ensures that the physician will be paid for the E/M service, even though it was provided within the preoperative global period for the procedure code. Modifier -57 is for major procedures that have a 90-day postoperative global, Bloom says. Modifier -25 is for minor surgery.

You would bill either an outpatient consultation (99244-99245) or a hospital admission (99221-99223), Ferragamo says.

Modifier -57 should be used on the consultation or admission if you decide to perform major surgery (with a 90-day postoperative period) the next day. If, however, you decide to perform minor surgery (with a 10-day postoperative period) the next day, you do not need modifier -25 on the consultation or admission, Ferragamo says.