Urology Coding Alert

Question: Is it true that most new patient visits when the urologist counsels the patient about prostate cancer/robotic radical prostatectomy or kidney cancer/robotic partial or total nephrectomy can be billed as a Level 5 office visit because of decision making and complexity of care? For example, I have notes from our physician stating that a patient was seen for a diagnosis code related to prostate cancer. The physician documented 40 minutes of time spent with the patient and stated that more than half of that time was spent in face-to-face counseling and coordination of care. I think the visit should reach 60 minutes to justify a Level 5 code. What is the correct guideline?

North Carolina Subscriber

Answer: When coding for a new patient, the provider should spend 60 minutes of face-to-face time with the patient to meet the requirements of the Level 5 office code 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. … Typically, 60 minutes are spent face-to-face with the patient and/or family). In your case, the physician spent 40 minutes in the care of the patient. The appropriate code for this amount of time would be 99203 (… A detailed history; A detailed examination; Medical decision making of low complexity), which typically includes 30 minutes of face-to-face time with the patient. The next level code 99204 (A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity …) requires 45 minutes face-to-face with the provider. However, mere counselling about prostate cancer, kidney cancer, or robotic surgery may not lead to high medical decision making.

Keep these points in mind when selecting the correct E/M codes:

• Per Documentation: If the documentation can support comprehensive history, comprehensive examination and medical decision making of high complexity, you can bill 99205.
• Comprehensive history: Expended HPI with 10 system review of systems (ROS) along with Past, Medical, Family, Surgical and Social history well documented in the records.
• Comprehensive Examination: 8 organ system examination
• Medical Decision Making: High level in 2/3 of Number of diagnoses/Management options, amount and/or complexity of data received and Table of risk.

Meeting all of these parameters can lead to high-level medical decision making.