Radiology Coding Alert

Question: The physician saw a patient in his office for swelling of the leg that hadn't responded to conservative therapy. He made the decision to perform endovenous radiofrequency ablation. On the day of the procedure, the physician submitted to me an H&P (history and physical) for an established outpatient visit. He already made the decision for the procedure in his office several days prior. I thought a pre-procedure H&P to confirm that the test is necessary and there are no contraindications was included in the RVUs for the procedure itself. Can this H&P be billed on the same day as 36475? Codify Member Answer: You're correct that you should not report the related H&P on the same day as the ablation (36475, Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated). A brief related history, exam, and medical decision making [...]