Urology Coding Alert

Question: We had a patient on the operating table with the urologist ready to perform a cystoscopy when the physician discovered the patient had a urinary tract infection. Therefore, the urologist cancelled the procedure. Can we code anything for this service?

Georgia Subscriber

Answer: Since the urologist did not actually perform the cystoscopic examination, you cannot report a cystoscopy procedure code. Instead, you should look at possibly reporting an E/M service code if the physician, for example, spent time with the patient indicating why he was canceling the procedure and then discussing the urinary tract infection treatment.

Example: If this service occurred in the office or in the hospital outpatient department, report an established outpatient E/M code (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...), depending on the encounter time spent in the discussion.

If the service occurred with a hospitalized patient, you should instead report 99221-99223 (Initial hospital care...) or 99231-99233 (Subsequent hospital care...) depending on the encounter time spent in the discussion. Your physician must clearly document within the medical records the time he spent counseling and coordinating the patient's care.

-- Answers to Reader Questions and You Be the Coder contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook; and Morgan Hause, CCS, CCS-P, privacy and com-pliance officer for Urology of Indiana LLC, a 31-urologist, two-urogynecologist practice in Indianapolis.