Urology Coding Alert

Question: A patient came in for the biopsy report after a 90-day global procedure. The doctor talked to the patient about results and different types of treatment for 15 minutes. How can I capture payment for this visit?

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Answer: You should report the appropriate office visit code, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...), based on the you're your urologist spent reviewing the results face to face with the patient. Since this visit is not a postoperative follow up examination related to the previous surgical procedure, but rather a visit to review the biopsy results with the patient, you can report the E/M service.

Caveat: Since you are within the surgical global, you must append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to your E/M code. Make sure your urologist documented clearly in the medical records the total time spent with the patient and the counseling and coordination of care discussed.