Urology Coding Alert

Question: How would I code this encounter? The test was conducted in our clinic and the urologist noted N40.1 (Benign prostatic hyperplasia with lower urinary tract symptoms) and R35.0 (Frequency of micturition) as the diagnoses. The documentation for the uroflowmetry is: “Today’s uroflow was reviewed with the patient. Patient was able to void 250 cc with a peak of 9.7 cc/s and the mean of 5.8 cc/s. Total flow time was 42 seconds. Flow pattern was obstructive.” There are no graphs scanned in like there sometimes are, so I can’t tell if it was done with electronic equipment.

Florida Subscriber

Answer: Based on the documentation, you should report 51736 (Simple uroflowmetry (UFR) (eg, stop-watch flow rate, mechanical uroflowmeter)) for this uroflowmetry test. Include N40.1 and R35.0 as the supporting diagnosis codes.

There is no indication that the urologist used calibrated equipment. Therefore, you cannot report 51741 (Complex uroflowmetry (eg, calibrated electronic equipment)).

Tip: Consider querying your urologist about this documentation, particularly if they normally include more data and graphs. This may be an opportunity for discussion and education on what documentation elements you need to help you choose the best, most accurate code to represent the work your urologist is actually performing.