Internal Medicine Coding Alert

Question: A new patient presents to the office with complaints of abdominal cramps and pain during urination. The patient also tells the internist that he has a family history of prostate cancer. After a level-three E/M service, the physician performs a post-voiding bladder scan using an ultrasound scanner. How should I report this scenario?

Montana Subscriber

Answer: You'll report the E/M and the scan separately, and be sure to include a diagnosis code to represent the patient's family history. Just to be safe, you should ask your carrier which diagnoses are covered for the bladder scan.

Reason: It will paint a more complete picture of the patient's condition for the payer, and it will help to prove medical necessity for the bladder scan. On the claim, report the following:

• 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging) for the scan

• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; medical decision-making of low complexity) for the E/M service

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99203 to show that the E/M and scan were separate services

• 788.1 (Dysuria) linked to 51798 and 99203 to represent the patient's urination pain

• 789.00 (Abdominal pain; unspecified site) linked to 51798 and 99203 to represent the patient's cramping

• V16.42 (Family history of malignant neoplasm; prostate) linked to 51798 and 99203 to represent the patient's family history.