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 [...]