Urology Coding Alert

To avoid confusion over code choice for your Medicare and private payer patients, and to calculate at what point the service will require a prolonged services add-on code, use the following chart.

Remember: Per the 2023 final rule, CMS is still not recognizing consult codes, which is why you won’t be able to use a prolonged service G code in addition to 99245 or 99255.

Example: Your urologist provides inpatient care lasting 95 minutes for a patient who has just been admitted to the hospital for treatment related to their new bladder cancer diagnosis. If the patient has private insurance, bill 99223 and +99418 as “+99418 may be used as soon as the total time [75 minutes] has been exceeded by 15 minutes,” according to Kelly Loya, CPC, CHC, CRMA, CPhT, CHIAP, associate partner at Pinnacle Enterprise Risk Consulting Services, Charlotte, North Carolina.

However, for a Medicare patient, you would not be able to bill 99223 with G0316 in this situation as even though 99223 may have been exceeded by 15 minutes, the code’s descriptor tells you not to report G0316 “for any time unit less than 15 minutes.” In this case, the unit of the prolonged service time, five minutes, is less than 15 minutes, so you will only bill Medicare for the 99223 service.