Urology Coding Alert

Question: A patient had 10 years of medical records sent to our urologist for review. Much of the information was not relevant to the patient’s current condition or the treatment plan. Is there a way to bill for the urologist’s time reviewing these records?

Texas Subscriber

Answer: You may use codes for prolonged service without face-to-face patient contact for records review before or after an E/M visit. Those codes are 99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour) and add-on code +99359 (… each additional 30 minutes [List separately in addition to code for prolonged service]). When using these codes, your urologist must provide appropriate documentation, including the amount of time spent reviewing the records. 

Remember: Not all payers recognize these codes. Some commercial payers and workers comp usually pay for the codes, as do some Medicaid carriers. Unfortunately, Medicare does not. For payers that don’t pay for 99358-99359, you can account for the work in the E/M service itself.

Although CPT® does not include the time associated with records review in the E/M code descriptors, “the pre- and post-face-to-face work associated with an encounter was included in calculating the total work of typical services in physician surveys.” Consequently, the service described by the E/M codes “is a valid proxy for the total work done before, during, and after the visit,” CPT® states.

On the other hand, if your urologist reviews the records and writes a summary of those records, you may be able to raise the level of medical decision-making (MDM) — this particularly applies to the “review of data” component of the MDM including the tests ordered or medical records reviewed — which may allow you to choose a higher-level E/M service when combined with the history and examination. 

Medicare gives two points for summarizing medical history. For instance, if your urologist orders and reviews a lab result and an ultrasound, and then adds the medical chart review, this increases the data category of the MDM to a moderate level.  If risk to the patient is moderate, this may lead to moderate-complexity MDM. When combined with a detailed history and examination, you may have a level-four established patient service (99214, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity).