Part B Insider (Multispecialty) Coding Alert

Published on Thu Oct 20, 2005 PDF

Question: I have documentation for a prostate brachytherapy patient showing that the attending oncologist took an oral history, performed a physical exam, considered several treatment options and consulted with the patient's family for a considerable amount of time. What level E/M service is required on the claim?


Ohio Subscriber


Answer: Remember, the first encounter with a brachytherapy patient is usually quite involved because the physician has to rule out other treatment modalities before deciding on brachytherapy. Based on your documentation, you may be able to report this encounter as a level five E/M service. Your claim may include:

• 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three components: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity...) when the encounter is a new patient.

• CPT 99215 (Office or other outpatient visit for the evaluation and management of an established patient...) when the encounter is an established patient.

• 99245 (Office consultation for a new or established patient...) if the service was a consultation. You should report 99245 for consults whether the patient is new or established.

Important: You must prove medical necessity for this high level of service. Whether you report 99205, 99215 or 99245, add ICD-9 code 185 (Malignant neoplasm of prostate) to the claim as the primary diagnosis for the patient's visit. The physician's documentation should include the malignant neoplasm as the primary diagnosis.