Urology Coding Alert

Question: A urologist performs a cystoscopy and then reports the results to the patient or informs them of their options. Should I consider the discussion in the cystoscopy reimbursement? Or can I bill an E/M charge as well?

Michigan Subscriber

Answer: With any service, procedure, or diagnostic test, if the results are normal and the urologist simply meets with the patient to tell him that the results were normal, then you should include that in the coding for the test/procedure/etc. -- in this case, the cystoscopy, such as 52000 (Cystourethroscopy [separate procedure]).

Exception: If the cystoscopic examination uncovers a problem and your urologist spends a significant amount of time with the patient explaining the results, the treatment options, the plan of care, etc. you may be justified in billing a separate E/M service code, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...). The key is: Was there "counseling and coordination of care"? When your urologist provides this type of service you should bill on the time spent face-to-face with the patient.

Example: Your urologist did a cystoscopic examination and found a bladder tumor. He meets with the patient and suggests hospitalization, special x-rays and tests, and a transurethral resection of the tumor. The urologist is counseling the patient about the problem and his options, and is also coordinating his future care. You can report an established patient office visit based on time.