EM Coding Alert

Question: A patient came to our office for a urodynamics CMG/voiding pressure study. She did not see the physician during the visit. The physician interpreted the results later that day. Can we have the patient return a week later and bill the appropriate E/M code?

Arizona Subscriber

Answer: If the patient returns to the physician to collect the results of a normal CMG/voiding pressure study performed the previous week, and the physician does not change or start a new treatment plan, you should not report a separate E/M code. You will only submit code 51728 (Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure), any technique) for the actual study.

However, if because of the results of the recent urodynamic study the physician then revises the treatment plan or starts a new treatment regimen and discusses this at length with the patient, a face to face E/M service based on time spent may be billed for the recent follow-up visit.

Also, if the patient has a new medical condition that your physician addressed on the follow-up visit day, youcan report the appropriate E/M code associated with that condition.