Urology Coding Alert

Question: A patient comes in for straight catheter teaching. The nursing staff does the education. In order to bill an E/M, what would need to be documented in the patient’s chart? Would we bill 99211 or 99212? I am leaning toward 99211 because it is only education. 

California Subscriber

Answer: The highest code a nurse can bill is 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services), no matter how much time she spends with the patient. 

Documentation: There must be a brief history and physical examination performed as well as a plan of care expressed. All must be included in the chart documentation as well as the teaching.

Supervision: Also, the urologist must be in the office suite to provide supervision if required. Send the claim in the name and numbers of the urologist present in the office suite. 

If the nurse performs a straight catheterization during the teaching, you may also bill 51701 (Insertion of non-indwelling bladder catheter [eg, straight catheterization for residual urine]). Add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the 99211 and see if your payer will reimburse you for both codes. Whether or not you are paid for the catheterization and E/M service will depend on the payer and your documentation.