Urology Coding Alert

Focus on the right components to bring in $15 per exam

Knowing how the CPT Rules apply for new patients, established patients, consultations and face-to-face counseling can keep you from undercoding evaluation and management services. Keep your E/M coding sharp - decide how to report each scenario below for airtight claims.

Scenario #1: Consultation, New Patient

A primary-care physician requests your urologist's opinion regarding a 70-year-old patient with elevated PSA levels. The urologist takes a detailed history, performs an expanded problem-focused examination, and uses straightforward decision-making.

Coding: Report 99242 (Office consultation for a new or established patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making).

Why that code? When you're billing a code from the 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient) or 99241-99245 (Outpatient consultations) series, you determine the level of E/M code based on all three key components: history, examination and medical decision-making, says Rachel Reyes, CPC, coding specialist for urology Associates of Central California in Fresno. You must choose the "lowest common denominator" - the code that matches the lowest-level service provided.

In this case, even though the urologist took a detailed history, you must base the code on the expanded problem-focused examination and straightforward medical decision-making (MDM). These lead you to code 99242.

Scenario #2: Established Patient, Follow-Up

A urinary tract infection patient presents for a follow-up exam and also complains of fever. The urologist's nurse takes a detailed history. The physician reviews her notes and performs a problem-focused exam with low-complexity MDM.

Coding: 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, and medical decision-making of low complexity).

Why that code? Since you only need two out of the three components to report an established patient office visit (99212-99215), you can base the level of code on the two highest-level components the urologist performed. In this case, that would be the detailed history and the low-complexity MDM.

Pitfall: If you coded the above encounter using the three-out-of-three-components rule, you'd report 99212 (... a problem-focused history, problem-focused examination, straightforward medical decision-making) based on the lowest component, an error that would cut roughly $15 from the claim.

Scenario #3: Established Patient, Face-to-Face Counseling

The urologist notes "TT = 45 minutes and F/F = 30 minutes" and indicates that the discussion addressed the treatment options for carcinoma of the prostate.

Coding: Report 99215 (... a comprehensive history, a comprehensive examination, medical decision-making of high complexity) for the visit's total 45 minutes.

Why That Code? The notations show that the urologist spent a total time (TT) of 45 minutes for the visit with 30 minutes face-to-face (F/F) with the patient counseling and addressing the patient's treatment options. You should simply select the appropriate E/M code based on the face-to-face time the urologist spent providing the encounter, says Teresa M. Thompson, CPC, CCC, a coding specialist and the owner of TM Consulting, a national medical consulting and management firm in Sequim, Wash.

Watch for: You can use time as the key factor as long as counseling and coordination of care dominates the encounter, with the urologist spending more than 50 percent of this encounter time on coordination and counseling of the patient. The total time the physician spent with the patient exceeds the 40 minutes typically associated with 99215. Therefore, the documentation will clearly support billing the higher-level E/M even if the history, examination and medical decision-making might only support a level-three visit (99213), equivalent to 15 minutes of encounter time.

In this scenario you use time alone to reach a level of charge: 15 minutes that encompasses the level three (established patient) and the 30 minutes for the counseling and coordination of care.