Urology Coding Alert

Question: Is there a procedure code for reviewing a voiding diary with a patient or is this included in an E/M service?

Minnesota Subscriber

Answer: There is no procedure code for reviewing a voiding diary.

Reviewing a voiding diary may provide elements needed for the history of the present illness (HPI), however. Assessing the duration of the voiding disorder, its severity, context, timing, and any associated signs or symptoms would provide at least four elements leading to a detailed HPI. That level of HPI would support a level-four E/M service, such as 99204 (Office or other outpatient service 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 moderate complexity...) or 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 ...).

In addition a voiding diary would provide the chief complaint and a partial review of systems (ROS).