Internal Medicine Coding Alert

Question: The internist performs a level-two E/M for a new patient. The results of the evaluation lead the internist to suspect diabetes, so he performs a non-automated dipstick urinalysis. Can we report both a urinalysis and an E/M code?

Alabama Subscriber

Answer: If the internist performs a lab test in addition to an E/M service for the same patient during the same encounter, you can typically report an E/M and a procedure code. On the claim, report the following:

• 81002 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy) for the urinalysis

• 99202 (Office or other outpatient visit for the E/M of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision-making) for the E/M.

Modifier 25 alert: Depending on the payer, you may need to append modifier 25 to the E/M. Medicare does not require modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) when you perform an E/M and a procedure without a global period, but some payers might want modifier 25.

Best bet: Submit the claim however the insurer wants you to. If you don't know a particular insurer's policy on this issue, contact a representative before filing.