Urology Coding Alert

Thorough documentation ensures payment for your urologist's E/M services

Determining what you can report when your urologist orders diagnostic tests and urological procedures that involve a technician's work can be a common challenge in coding -- and if you choose wrong, you could be costing your practice hundreds in lost reimbursement.

Look at this clinical scenario sent to us from subscriber Beverly Baerg, RN, clinical charge nurse for Urology Associates of South Texas PA in McAllen, Texas.

Scenario: A few days ago the urologist saw Mr. Smith and ordered a prostate-specific antigen test (PSA), which was performed in the office that day, a renal ultrasound, and a voiding cystourethrogram (VCUG).

Today Mr. Smith came in and the sonographer performed a renal sonogram, which she documented before passing the film and the patient on to the procedure technician to perform the VCUG. When the procedure technician completed and documented the VCUG, he placed all the films on the viewbox for the physician. 

The physician then reviewed the chart and dictated his interpretation of the renal sonogram, the VCUG, and his plan for treatment. The urologist then met with the patient, explained the findings and the films to the patient, discussed treatment plans with him, gave him the PSA results from the specimen drawn at the previous visit, and gave him samples of Uroxatral.

The physician noted "dictated" beside the technicians' records of the procedures, made a note of the medication samples given to the patient, checked the superbill to be sure all the procedures and appropriate diagnoses are marked, and marked office visit code 99213.

Dilemma: The coder is expected to post charges to the patient's account based on the superbill and what is documented, knowing that the physician always discusses the results with the patient on the same day and that the dictated report will be attached to the chart in a few days.

Can the coder report the physician's office visit in addition to billing for the renal sonogram and the VCUG? Does the interpretation of the radiological studies mean thecoder should report only the professional component of the studies?

Code E/M Based on Time

Because the documentation of the encounter clearly identifies that the diagnostic imaging and interpretation are separate from the urologist's visit with the patient, you can report a separate E/M encounter.

"In the scenario described, the professional component of the diagnostic imaging services is the interpretation, appropriately documented separately from the visit with the patient by report," says Morgan Hause, CCS, CCS-P, privacy and compliance officer for urology of Indiana LLC, a 31-urologist, two-urogynecologist practice in Indianapolis. "This is clearly separate from the encounter with the patient."

Choosing the code: When the physician meets face-to-face with a patient in the office for coordination of his care, you may code the office visit based on time alone. In this scenario, it's appropriate to bill based on time for both the counseling and the coordination of care. In an office setting, you base the coding on the total face-to-face time with the patient. In addition, to qualify, the urologist must spend 50 percent or more of the encounter time with the patient face-to-face in counseling and coordinating the patient's care.

Remember: While you do not need to have a  documented chief complaint, vital signs or other history in order to bill on time alone, your urologist must document the exact time he spent face-to-face with the patient discussing his findings and treatment options.
 
The physician needs to record the total amount of face-to-face time as well as the total amount of counseling and coordination of care time. And the urologist should document the nature of the discussion and what he did, such as providing samples and literature.

Example: If the urologist documented all of the required information in the medical record, indicating that he spent 15 minutes of total face-to-face time, greater than 50 percent of which was spent on counseling and coordination of care, the coder should report CPT 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually the presenting problem[s] are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family), says Michael A. Ferragamo, MD, FACS, clinical assistantprofessor of urology at the State University of New York in Stony Brook.

Don't Miss Out on Radiological Codes

When the documentation identifies radiological tests and examinations that are separate from the office visit, remember to report those services in addition to the E/M service code. In the scenario above, you should also report the renal sonogram and the VCUG.

For the renal sonogram, you can report both the technical and professional components (the global) for the service as long as the urologist provides general supervision. This means that the physician does not need to be in the office suite, but available by phone and able to get to the office if his assistance is needed.

"Since the urologist was in the office when the technician performed the renal study, he can bill the global (professional and technical components)," Ferragamo says. Therefore, you should report 76775 (Ultrasound, retroperitoneal [e.g., renal, aorta, nodes], B-scan and/or real time with image documentation; limited) for the renal sonogram.
 
Caution: How you report the VCUG, however, depends on whether the urologist was in the room while the test was performed. CMS rules require personal supervision for the technical component of a VCUG. The urologist must be in the room where the study is being performed.

Therefore, to also report the technical component of the study, the urologist must be in the imaging room providing personal supervision. If the urologist was in the room during the test, report 74455 (Urethrocystography, voiding, radiological supervision and interpretation) with no modifiers. If he wasn't in the room, you can only bill the interpretation, or professional component. Use 74455 but append modifier 26 (Professional component) to indicate that the urologist only performed the interpretation.

Bonus: For the PSA test that the urologist performed during the previous visit, you would bill for the PSA testing as well as the blood draw because the PSA determination was also performed in the office by the office laboratory. Report 84153 (Prostate specific antigen [PSA]; total) and 36415 (Collection of venous blood by venipuncture).

Warning: You should not charge an E/M service if the encounter was only to report normal test results. This is included in the payment for the test. However, in the abo
ve case, counseling and coordination of care for the patient was discussed in addition to the reporting of the laboratory and radiological results, so you are able to report the office visit as well.