Primary Care Coding Alert

Question: If a patient presents to the office for a procedure not requiring a visit with the doctor (e.g., urine dip, injections), what is the proper way to code to cover the nurses time?

Texas Subscriber

Answer: If the nurse is performing an evaluation and management (E/M) service (i.e., reviewing patient history, performing patient exam and/or medical decision-making) in addition to the procedure, then you can bill an E/M code. In most cases, the appropriate E/M code would be 99211 (office or other outpatient visit for the evaluation and management of an established patient with minimal presenting problems).

Otherwise, if only the procedure is being done, then only report the CPT code for that service, i.e., urinalysis 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).

Answers for Reader Questions were provided by: Cynthia DeVries, RN, BSN, CPC, coding and reimbursement coordinator for Lee Physicians Group, a 140-provider, multispecialty practice in Fort Myers, Fla.; and Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Systems Inc., a billing and coding firm that supports urology and family practice physicians in Broomfield, Colo.