Urology Coding Alert

Question: If my urologist has a patient return to the clinic for an annual cystoscopic examination in follow up for a bladder tumor resected two years ago, and he performs an examination and reviews the history during the visit, can I bill an E/M code with the cysto if he didn't have a separate diagnosis?

Oregon Subscriber

Answer: Whether or not you can separately report the E/M service using a subsequent office visit code such as 99212-99215 (... established patient, subsequent office visit) depends on some details about the patient's visit.

Option 1: If the cystoscopy was a scheduled procedure, scheduled at the time of a recent encounter with the patient, then you should not separately bill for an E/M service just  to repeat the findings and history previously obtained at that first visit.

Option 2: If the urologist examines a patient he is following for a bladder tumor removed in the past, and this visit is a regular follow up examination in the further care and evaluation of the patient with this past diagnosis, then you can bill for the examination that you would normally have performed in the follow up of a cancer patient even though you are also providing a cystoscopic examination as part of his care during the same encounter.

Option 3: If following a scheduled cystoscopic examination where the urologist finds a recurrent bladder tumor, the doctor discusses with the patient, face to face, and counsels the patient and coordinates his future care for this recurrent tumor, you may also bill an E/M service for this discussion with the patient based on time alone while also billing for the cystoscopic examination.