EM Coding Alert

Question: A patient came to our office for a urodynamics cystometrogram (CMG)/voiding pressure study. She did not see the physician during the visit. The physician interpreted the results later that day. Can we have the patient return a week later and bill the appropriate E/M code?

Arizona Subscriber

Answer: If the patient returns to the physician to collect the results of a normal CMG/voiding pressure study performed the previous week, and the physician does not change or start a new treatment plan, you should not report a separate E/M code. You will only submit code 51728 (Complex cystometrogram [ie, calibrated electronic equipment]; with voiding pressure studies [ie, bladder voiding pressure] any technique) for the actual study.

However, if because of the results of the recent urodynamic study the physician then revises the treatment plan or starts a new treatment regimen and discusses this at length with the patient, a face-to-face E/M service based on time spent may be billed for the recent follow-up visit.

Also, if the patient has a new medical condition that your physician addressed on the follow-up visit day, you can report the appropriate E/M code associated with that condition.