Turn to V25.x for your diagnosis code option.
Vasectomies are very common in most urology practices. But choosing the proper codes to report can sometimes prove very challenging, right from the pre-vasectomy “consultation” visit that most urologists perform. You could be costing your practice hundreds over the course 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 patient to discuss the procedure and makes sure that the patient understands the outcome of the procedure and then undergo this elective sterilization. You should report this office visit using the appropriate E/M code, says Kelly Young, a coder with Scottsdale Center for Urology in Scottsdale, Ariz.
The real challenge comes when you try to figure out whether you should 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 a new or established patient…), a new patient (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient…), or established patient (99211-99215, Office or other outpatient visit for the evaluation and management 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 patient visit (99203), you’ll earn $91.97 (the unadjusted fee for 99203, 2.55 RVUs, times the 2009 conversion rate of $36.0666) in addition to the procedure code, and if your urologist performs a level-three consultation, you’ll earn $125.15 (the unadjusted fee for 99203, 3.47 RVUs, times the 2009 conversion rate of $36.0666) in addition to the procedure code.
Remember: If the patient is new to your office, report a new patient visit using codes 99201-99205. However, if the urologist (or another urologist in the same practice) has seen the patient within the past three years, report an established patient office visit (99211-99215), and not a new patient 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 request from the requesting physician; a record 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 recent rule changes for consultations come from Medicare 2006 policy changes (Transmittal 788) and since most men seeking vasectomies for sterilization do not have Medicare as their primary insurance carrier, the patients sent to urologists by physicians most often represent consultation requests, hence, they should be billed and coded accordingly if all criteria for a consultation are met.”
Diagnosis aid: The most appropriate ICD-9 code for the pre-vasectomy examination, whether it’s a consultation or a new/established patient visit is V25.09 (Encounter for contraceptive management; general 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 examination 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 service in most cases.
Check, which diagnostic code is preferred by your payer. The Scottsdale Center for Urology uses V25.2 as the diagnosis 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 separate E/M code, the E/M service must go above and beyond the E/M that’s inherent to the procedure.
Avoid bundled payment: Your urologist can conduct the service on separate 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 patient time to review his options and make the final decision about surgery. Above that, your office will have time to review the patient’s benefits.
Alice Kater, CPC, PCS, coder for Urology Associates of South Bend, Ind says, “We never perform the procedure the same day as the vas consultation. The patient and wife/partner will come in for the consult, view a movie, and speak extensively with the physician following the examination and review of systems. When they leave the physician, they schedule their procedure for the next available, and convenient, vas opening.”
3. Select a Code Based on the Type of Procedure
You’ll have to go through the documentation to see which technique your urologist used, so that you can report the actual vasectomy procedure. Then choose one of these three codes:
- 55250 – Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s). “This CPT Codes is the most common 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 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 suturing the ends, on both the left and right sides. So don’t change your urology coding even if your urologist cuts and sutures only one side (for a patient 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], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) for private or commercial 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 commercial carriers that will still reimburse for local anesthesia administered by the urologist and for a tray charge. Check with the specific carrier. One may bill private or commercial 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, usually at the same time a general 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, equipment used, and time involved.
4. Include Semen Analysis in the Procedure Code
After the vasectomy, the urologist must examine the semen to determine 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, outside laboratory evaluations will be necessary and that would result in an additional cost to the patient. However, under these circumstances your urologist should never lower his fee or modify his urology coding. Practices often make special arrangements with most laboratories for a reduced fee for a limited semen examination looking only for the presence or absence of sperm.