Anesthesia School - Get 5 Extra in Vasectomy-Related cost With This 4-Step Coding Process
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Vasectomies are very base in most urology practices. But choosing the permissible codes to report can sometimes prove very challenging, right from the pre-vasectomy "consultation" visit that most urologists perform. You could be costing your institution hundreds over the procedure of one year if you're not billing out each piece of the vasectomy process. Here are four steps to ensure that you capture all the reimbursement your urologist deserves.
1. Don't be in a hurry to assign consult codes for the first visit
Prior to performing a vasectomy process a urologist meets with the sick person to discuss the procedure and makes sure that the sick person understands the outcome of the procedure and then feel this elective sterilization. You should report this office visit using the accepted E/M code, says Kelly Young, a coder with Scottsdale center for Urology in Scottsdale, Ariz.
The real challenge comes when you try to shape out either you should report an office visit E/M code or a consultation code.
Depending on your urologist's documentation, you can pick from the consultation codes (99241-99245, Office consultation for a new or established patient...), a new sick person (99201-99205, Office or other sick person visit for the estimate and supervision of a new patient...), or established sick person (99211-99215, Office or other sick person visit for the estimate and supervision of an established patient...) codes.
Don't lose out on your Dollars: You would be sacrificing on your Dollars if you skip reporting the pre-vasectomy office visit. Suppose, your urologist performs a level-three new sick person visit (99203), you'll earn .97 (the unadjusted fee for 99203, 2.55 Rvus, times the 2009 conversion rate of .0666) in addition to the procedure code, and if your urologist performs a level-three consultation, you'll earn 5.15 (the unadjusted fee for 99203, 3.47 Rvus, times the 2009 conversion rate of .0666) in addition to the procedure code.
Remember: If the sick person is new to your office, report a new sick person visit using codes 99201-99205. However, if the urologist (or another urologist in the same practice) has seen the sick person within the past three years, report an established sick person office visit (99211-99215), and not a new sick person visit.
Beware: Don't let the term "consultation" in the physician's documentation trick you. Often practices, physicians, and even patients refer to the pre-vasectomy visit as a consultation. However, to report a consultation code (99241-99245), the visit must meet the requirements of a consultation. There must be a documented invite from the requesting physician; a report of the urologist stating his findings, opinions, and advice in the patient's chart; and a report that's sent back to the requesting doctor.
Michael A. Ferragamo Md, Facs, clinical assistant professor of urology, State University of New York, Stony Brook says, "Since the new rule changes for consultations come from Medicare 2006 procedure changes (Transmittal 788) and since most men seeking vasectomies for sterilization do not have Medicare as their primary guarnatee carrier, the patients sent to urologists by physicians most often relate consultation requests, hence, they should be billed and coded accordingly if all criteria for a consultation are met."
Diagnosis aid: The most accepted Icd-9 code for the pre-vasectomy examination, either it's a consultation or a new/established sick person visit is V25.09 (Encounter for contraceptive management; normal counseling and advice; other).
Important point: Many payers have a perception that code V25.09 is a "family planning advice," and pertain only to the female partner, and hence, they will deny payment for any pre-vasectomy test of the male when you use this diagnosis. So use V25.2 (Encounter for contraceptive management; sterilization, admission for interruption of...vas deferens) in its place, with this you can expect payment for a pre-vasectomy assistance in most cases.
Check, which diagnostic code is preferred by your payer. The Scottsdale center for Urology uses V25.2 as the analysis code. However, "we bill... With V25.09," says Kim Kerckhoff, Cca, coder for Alpine Urology in Anchorage, Alaska.
2. Use modifier 57 for Same-Day E/M and Procedure
If your urologist performs the vasectomy procedure on the same day as the pre-vasectomy office visit make sure that you append modifier 57 (Decision for surgery) to the E/M code you report. Also ensure that the urologist's documentation supports a cut off E/M code, the E/M assistance must go above and beyond the E/M that's inherent to the procedure.
Avoid bundled payment: Your urologist can escort the assistance on cut off days if you want to make sure that your payer will not bundle the pre-vasectomy visit with the vasectomy procedure. Many urologists do this anyway to give the sick person time to narrate his options and make the final decision about surgery. Above that, your office will have time to narrate the patient's benefits.
Alice Kater, Cpc, Pcs, coder for Urology company of South Bend, Ind says, "We never perform the procedure the same day as the vas consultation. The sick person and wife/partner will come in for the consult, view a movie, and speak extensively with the doctor following the test and narrate of systems. When they leave the physician, they agenda their procedure for the next available, and convenient, vas opening."
3. go for a Code Based on the Type of Procedure
You'll have to go straight through the documentation to see which technique your urologist used, so that you can report the actual vasectomy procedure. Then pick one of these three codes:
55250 - Vasectomy, unilateral or bilateral (separate procedure), together with postoperative semen examination(s). "This Cpt Codes is the most base code used for vasectomy for voluntary sterilization," Ferragamo explains.
55450 - Ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure). "Coders rarely use this code for a vasectomy for voluntary sterilization," Ferragamo says.
55559 - Unlisted laparoscopy procedure, spermatic cord for a laparoscopic vasectomy.
Add V25.2 to the vasectomy procedure, says Kerckhoff.
Clue: You should report 55250, 55450, or 55559 just once per sick person regardless of either the urologist performs the procedure on one or both sides. The urologist usually, but not always, performs the procedure, cutting the vas deferens and suturing the ends, on both the left and right sides. So don't turn your urology coding even if your urologist cuts and sutures only one side (for a sick person having only one testicle).
Note: These codes also include the local or regional anesthesia that the urologist administers, so do not code any local anesthesia administered for those services separately.
Surgical trays: Use the Hcpcs code A4550 (Surgical trays) or Cpt code 99070 (Supplies and materials [except spectacles], in case,granted by the doctor over and above those commonly included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) for incommunicable or market payers, few of them reimburse for a surgical tray/supplies.
"Medicare will not reimburse for anesthesia administered by the surgeon or urologist, or for tray charges," Ferragamo warns. "However, there are a few market carriers that will still reimburse for local anesthesia administered by the urologist and for a tray charge. Check with the definite carrier. One may bill incommunicable or market carriers Hcpcs code S0020 (Injection, bupivicaine Hcl, 30 ml) for reimbursement of the anesthetic agent used," he adds.
There is no Cpt code for laparoscopic vasectomy so when your urologist performs this procedure, commonly at the same time a normal surgeon is performing a laparoscopic hernia repair, report the unlisted code 55559.
Hint: Make sure that you submit a detailed report to your payer and compare, or benchmark, the laparoscopic vasectomy to 55550 (Laparoscopy, surgical, with ligation of spermatic veins for varicocele), with respect to the surgical work, technology, tool used, and time involved.
4. include Semen analysis in the procedure Code
After the vasectomy, the urologist must explore the semen to decree the eventual absence of sperm. These examinations are included in the procedure code, so your urologist should document the service, but you should not report them separately.
If your office laboratory is not credentialed (Clia certification) to perform these post-vasectomy semen analyses, surface laboratory evaluations will be requisite and that would ensue in an supplementary cost to the patient. However, under these circumstances your urologist should never lower his fee or modify his urology coding. Practices often make extra arrangements with most laboratories for a reduced fee for a tiny semen test looking only for the nearnessy or absence of sperm.
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