Urology Coding Alert

Question: Should I include head and face, eyes, ENT, and skin when assigning an E/M code for the physical portion of a single organ system examination?

Indiana Subscriber

Answer: Although the 1995 E/M guidelines never really had a single organ system examination for urology, the 1997 E/M guidelines do have one that has been used and accepted by urologists. If you are using the 1997 E/M guidelines, you can only count the examination of skin toward a specific E/M level. Head, eyes, ears, nose and throat (HEENT) examinations may be performed but have no value in determining a level of care under the 1997 guidelines.
 
When you use the 1995 E/M guidelines, the physical exam portion of the E/M service also requires that the physician perform an examination of the affected body system, which - if your physician is a urologist - is probably the genitourinary system.
 
Only new patient E/M services and consultations require you to meet all three documentation requirements outlined in the code descriptors. Established patient codes require you to meet two of the three documentation requirements outlined in the code descriptors. As a result, coders often use the medical decision-making and history components to determine an established patient E/M level and use the examination component as their wild card.