Urology Coding Alert

Question: My urologist did a counseling session with the parents of a minor regarding the minor's proposed treatments. He spent a good 20 to 30 minutes with the parents answering questions. Is there a code I can use for this?

California Subscriber

Answer: You should bill this as an E/M encounter based on time. If the counseling and/or coordination of care dominates -- makes up more than 50 percent of the physician/patient and/or family encounter (face-to-face in office or other outpatient settings), time alone may be the key or controlling factor to qualify for a particular level of E/M service, such as 99201-99215. Base your choice of an E/M service on the specific time your urologist documented in the patient's chart. If the encounter lasted between 20 and 30 minutes, 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 ... Physicians typically spend 25 minutes face-to-face with the patient and/or family) is likely your best code choice for an established patient visit.