Level of service for vasectomy prompts coding confusion

Our group has been reporting a level 3 new (99203) or established (99213) evaluation and management (E/M) code for visits for patients considering a vasectomy. Recently, some payers have been down-coding these visits to level 2 or sometimes even denying these codes altogether! What is the correct level of service for a vasectomy consultation visit?

Jonathan Rubenstein, MD

As we know, there is never a one-size-fits-all for coding scenarios based on the reason for the visit. The correct code for reporting any office or other outpatient E/M service would be based on the 2021 CPT office or other outpatient coding guidelines (found here: Code and Guideline Changes | AMA). Documentation must include a medically appropriate history and examination, the number and complexity of problems addressed at the encounter, the amount and/or complexity of data to be reviewed and analyzed, and the risk of complications and/or morbidity or mortality of patient management decisions made at the visit associated with the patient’s problem(s), the diagnostic procedure(s), and treatment(s). Additionally, one can document the total time spent on that patient on that day.

When choosing an appropriate code, use either Medical Decision-Making (MDM) or Time when determining the visit level. These items are well documented in the guidelines. If a patient meets the criteria for a certain level (MDM or Time), it would not be appropriate for an insurer to change that code without showing in the documentation where a certain level was not met. Therefore, an insurer cannot down-code without proof or justification. And because the guidelines and code level are not based on the reason for the visit but rather on the data outlined above, neither a provider nor an insurer can determine a code level based on the reason for the visit. It would need to be individualized based on the specific patient and how they fit into the E/M guidelines.

Mark Painter

Understanding that there are variabilities in patients and nuances and specifics concerning individual patients, we will do our best to answer your question based on some general guidance and analysis regarding an index patient who is relatively uncomplicated and presenting to the urologist to discuss a vasectomy.

First, we need to consider that a vasectomy procedure (CPT 55250) is a 90-day global procedure. The global period for 90-day global CPT codes includes any associated E/M codes on the day of or preceding the procedure. An E/M code can only be reported during that period if a separate and identifiable service is performed. In this case, if the initial consultation and discussion for the vasectomy procedure was carried out, this could be reported using modifier -57 (decision for surgery). Please note that a complete note including the history, examination, and risk discussion must be appropriately documented as it would with any office visit. We have often seen that this documentation is lacking, and that is the reason for nonpayment. Without such documentation, the E/M code should be denied. One cannot automatically report an E/M code and assume it will be paid if there is no documentation to show the work being done. If the documentation simply reflects a discussion of the risks and benefits of the vasectomy as well as the procedure and recovery, it should be considered a pre-operative encounter, which should not be reported when provided within the global period.

If the visit is truly a discussion about the patient’s current lifestyle and is focused on providing professional guidance on whether a vasectomy is an appropriate choice, based on the discussion and supporting documentation the service would be considered a family planning visit and separately billable. Diagnosis code Z30.09 (Encounter for other general counseling and advice on contraception) should be reported to categorize this visit appropriately. If the visit is within the global period and results in a decision to proceed with the vasectomy, modifier -57 should be appended to the E/M code.

If choosing a level of service based on the MDM, documentation must show that 2 of the 3 elements of MDM meet or exceed the level of service reported:

MDM Element 1: Number and complexity of problems addressed during the encounter

The first element in MDM is the presenting problem which is addressed at the encounter This can be a bit of a challenge as a patient considering family planning options is not directly translated into the new E/M guidelines. Problems that are considered as supporting a level 2 visit (straightforward) fall under this category, are stated to be minimal, and include 1 self-limited or minor problem. Following are the definitions from CPT 2025 from the American Medical Association (AMA):

Minimal problem: A problem that may not require the presence of the physician or other qualified health care professional, but the service is provided under the physician’s or other qualified health care professional’s supervision (see 99211, 99281).

Self-limited or minor problem: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.

We have discussed this issue with multiple urologists around the country. The patient is deciding whether to undergo a procedure of moderate risk with a permanent change to his current health status. This discussion is one that requires a physician or other qualified health care provider to provide the information necessary to make this life-changing decision. Additionally, the procedure or treatment solution requires the patient to consider a permanent change to his current life status. Therefore, the presenting problem would be considered more significant than those defined under the lowest level as the presenting problem.

A level 3 problem considered low under current guidelines includes the following: 2 or more self-limited or minor problems; or 1 stable, chronic illness; or 1 acute, uncomplicated illness or injury; or 1 stable, acute illness; or 1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care.

Although none of the definitions covered under the current guidelines fit the presenting problem well in this case, the CPT guidelines are clearly intended to reflect physician MDM and the related work and effort. To save space in this article, we can let you know that after considerable discussion, we have ruled out definitions meeting level 4 or level 5 for this element. The definition that most closely reflect the counseling and options for a patient considering a vasectomy do rise to the level of service that would be considered is an acute, uncomplicated illness or injury:

Acute, uncomplicated illness or injury:recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness.

We would not consider fertility and the consideration of permanently changing the patient’s fertility status through medical intervention a short-term problem. However, again after discussion with multiple practicing urologists, we would consider the problem equivalent to many urologic presentations in relative work effort, risk to the patient’s long-term health status, and education considerations for shared decision-making in this category. In addition, unlike the straightforward presentation that typically requires no intervention to resolve the problem (also known as self-limited, defined as not needing intervention for resolution), this concern is resolved only with surgical intervention, albeit one that would typically lead to a full recovery without functional impairment.

Therefore, based on the CPT guidelines, this consultation should be scored as a level 3 (low) presenting problem for this element of MDM.

Element 2: Amount and/or complexity of data to be reviewed and analyzed

Typically, there is no data (such as urine analysis, postvoid residual, prostate-specific antigen level, etc) that is medically necessary to review and/or order for an otherwise healthy man to evaluate or treat a patient considering vasectomy. Therefore this element of MDM would typically support a level 2, and therefore would not typically be used in level selection for the MDM of this visit. If there was a medically necessary reason to review or order labs or diagnostic tests (for example, due to a patient’s underlying health condition that may affect their risk of surgery and the patient’s decision), then the appropriate data level should be chosen based upon the MDM guidelines.

Element 3: Risk of complications and/or morbidity or mortality of patient management

The amount of risk to the patient and provider associated with a vasectomy, if it is recommended and/or scheduled, would support a moderate risk (level 4). This scoring is based on comparison with other procedures offered by urologists, such as ureteroscopy with laser lithotripsy and bladder tumor resections on otherwise healthy patients. Most payers and auditors agree that vasectomy fits the moderate category.

With the requirements for an E/M code as noted above, we agree with you that the supporting documentation, if appropriately documented, would support a level 3 outpatient visit for a visit regarding counseling for contraception or family planning.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.