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Get $125 Extra in Vasectomy-Related Payment With This 4-Step Coding Process
To set the diagnostic code, go to V25.x.
Vasectomy is very common in most urology practices. However, selecting the appropriate codes for reporting can sometimes be a challenge, starting with the pre-vasectomy “consultation” visit that most urologists perform. It could cost your practice hundreds over the course of a year if you don’t bill for every part of your vasectomy. Here are four steps to ensure you get all the reimbursement you deserve from your urologist.
1. Do not rush to assign consultation codes for the first visit
Before a vasectomy procedure is performed, a urologist meets with the patient to discuss the procedure and make sure the patient understands the outcome of the procedure and then undergoes elective sterilization. You should report this office visit with the appropriate E/M code, says Kelly Young, a coder at Scottsdale Urology Center in Scottsdale, Ariz.
The real challenge comes when trying to figure out whether to report an office visit E/M code or a consultation code.
Depending on your urologist’s documentation, you can choose from the consultation codes (99241-99245, Office consultation for new or established patients…), for new patients (99201-99205, Office or other outpatient visit for evaluation and treatment). new patient…), or established patient (99211-99215, Office or other outpatient visit for evaluation and treatment of an already established patient…) codes.
Don’t lose your dollar: You’d be sacrificing your dollar if you skip the pre-vasectomy office visit report. Let’s say your urologist performs a level three new patient visit (99203), you earn $91.97 (the unadjusted rate for 99203, 2.55 RVUs multiplied by the 2009 conversion rate of $36.0666), and if your urologist If you perform a third-level consultation, you will earn $125.15 in addition to the procedure code (the unadjusted fee for 99203, 3.47 RVUs, times the 2009 conversion rate of $36.0666).
Remember: If the patient is new to your office, report the new patient visit using codes 99201-99205. However, if the urologist (or another urologist in the same office) has seen the patient within the past three years, report an established office visit (99211-99215) and not a new patient visit.
Beware: Don’t be fooled by the term “consultation” in your doctor’s documentation. Practices, doctors, and even patients often view the pre-vasectomy visit as a consultation. However, to report a consultation code (99241-99245), the visit must meet the requirements of the consultation. There must be a documented request from the requesting physician; the urologist’s note containing his findings, opinion and advice in the patient chart; and a report that is returned to the requesting physician.
Michael A. Ferragamo MD, FACS, clinical assistant professor of urology at the State University of New York, Stony Brook, says, “Because the most recent changes in consultation rules stem from the 2006 Medicare policy changes (Transmittal 788), and because most men seeking a vasectomy for the purpose of sterilization, Medicare is not the primary insurance carrier, patients sent by doctors to urologists most often represent consultation requests, so they should be billed and coded accordingly if all the conditions for the consultation are met.”
Diagnostic help: The most appropriate ICD-9 code for a pre-vasectomy visit, whether a consultation or a new/specified patient visit, is V25.09 (Contraceptive treatment appointment; general counseling and advice; other).
Important point: Many payers feel that code V25.09 is “family planning advice” and applies only to the female partner, so they will refuse to test the male before vasectomy if you use this diagnosis. So use V25.2 (Appointment for contraceptive treatment; sterilization,…admission due to interruption of the vas deferens) instead, in most cases you can count on payment of the service before the vasectomy.
Check which diagnostic code is preferred by the payer. Scottsdale Center for Urology uses V25.2 as the diagnosis code. However, “we bill with V25.09,” says Kim Kerckhoff, CCA, coder at Alpine Urology in Anchorage, Alaska.
2. Use modifier 57 for Same-Day E/M and procedure
If your urologist is performing the vasectomy procedure on the day of the pre-vasectomy office visit, be sure to attach modifier 57 (Decision to Operate) to the reported E/M code. Also make sure the urologist’s documentation supports the separate E/M code, the E/M service must exceed the E/Mt associated with the procedure.
Avoid batch payments: Your urologist may perform the service on separate days if you want to make sure that your payer does not combine the pre-vasectomy visit with the vasectomy procedure. Many urologists do this anyway, so that the patient has time to review his options and make the final decision about surgery. In addition, your office will have time to review the patient’s care.
Alice Kater, CPC, PCS, coder at Urology Associates in South Bend, Ind., says, “We never do the procedure on the same day as the iron consultation. The patient and spouse come in for the consultation, watch a film and After examining and reviewing the system, talk extensively with the doctor. When they leave the doctor, they will schedule the procedure for the next available and convenient vacuum port.”
3. Select a code based on the type of procedure
You will need to review the documentation to see which technique your urologist used to report the actual vasectomy procedure. Then choose one of the three codes:
- 55250 – Unilateral or bilateral vasectomy (separate procedure), including postoperative sperm test(s). “This CPT codes it’s the most common code used for vasectomy for voluntary sterilization,” Ferragamo explains.
- 55450 – Ligation of the vas deferens (percutaneous), unilateral or bilateral (separate procedure). “Coders rarely use this code for vasectomy for voluntary sterilization,” says Ferragamo.
- 55559 – Unlisted laparoscopic procedure, spermatic cord for laparoscopic vasectomy.
Add V25.2 to your vasectomy procedure, says Kerckhoff.
Trace: You need to report 55250, 55450 or 55559 only once per patient, regardless of whether the urologist performs the procedure on one or both sides. The urologist usually, but not always, performs the procedure, cutting the vas deferens and sewing the ends together, both on the left and right side. So don’t change it urological coding even if your urologist only cuts and stitches one side (in a patient with only one testicle).
note: These codes also include local or regional anesthesia administered by the urologist, so do not separately code local anesthesia administered for those services.
Surgical trays: Use HCPCS code A4550 (surgical trays) or CPT code 99070 (supplies and materials [except spectacles]provided by the doctor together with the office visit or other services provided in general [list drugs, trays, supplies, or materials provided]).
“Medicare will not reimburse the cost of anesthesia or trays administered by a surgeon or urologist,” Ferragamo warns. “However, there are some commercial carriers that will still reimburse urologist-administered local anesthesia and the tray fee. Check with that carrier. You can bill private or commercial carriers HCPCS code S0020 (injection, bupivicaine HCL, 30 mL ) is the anesthetic agent used to reimburse his expenses,” he adds.
There is no CPT code for laparoscopic vasectomy, so when your urologist performs this procedure, usually when a general surgeon performs laparoscopic hernia repair, report unlisted code 55559.
Targeting: Be sure to provide a detailed report to the payer and compare or contrast laparoscopic vasectomy with 55550 (Laparoscopy, surgical, with ligation of spermatic veins for varicocele) regarding operative work, technology, equipment used, and it takes time.
4. Include semen analysis in the procedural code
After a vasectomy, the urologist should examine the sperm to determine if there is a lack of sperm. These tests are included in the procedure regulations, so your urologist will document the service, but do not report it separately.
If your office laboratory is not authorized (CLIA-certified) to perform post-vasectomy sperm analysis, outside laboratory evaluations will be required and this would incur additional costs to the patient. However, under these circumstances, your urologist can never lower your fee or change your urology coding. Practices often make special arrangements with most laboratories for a limited sperm test that only tests for the presence or absence of sperm.
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