Urology Coding Alert

Focus on the right components to bring in $15 per exam Knowing how the CPT Rules apply for new patients, established patients, consultations and face-to-face counseling can keep you from undercoding evaluation and management services. Keep your E/M coding sharp - decide how to report each scenario below for airtight claims.

Scenario #1: Consultation, New Patient A primary-care physician requests your urologist's opinion regarding a 70-year-old patient with elevated PSA levels. The urologist takes a detailed history, performs an expanded problem-focused examination, and uses straightforward decision-making.

Coding: Report 99242 (Office consultation for a new or established patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making).

Why that code? When you're billing a code from the 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient) or 99241-99245 (Outpatient consultations) series, you determine the level of E/M code based on all three key components: history, examination and medical decision-making, says Rachel Reyes, CPC, coding specialist for urology Associates of Central California in Fresno. You must choose the "lowest common denominator" - the code that matches the lowest-level service provided.

In this case, even though the urologist took a detailed history, you must base the code on the expanded problem-focused examination and straightforward medical decision-making (MDM). These lead you to code 99242. Scenario #2: Established Patient, Follow-Up A urinary tract infection patient presents for a follow-up exam and also complains of fever. The urologist's nurse takes a detailed history. The physician reviews her notes and performs a problem-focused exam with low-complexity MDM.

Coding: Report CPT 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity).

Why that code? Since you only need two out of the three components to report an established patient office visit (99212-99215), you can base the level of code on the two highest-level components the urologist performed. In this case, that would be the detailed history and the low-complexity MDM.

Pitfall: If you coded the above encounter using the three-out-of-three-components rule, you'd report 99212 (... a problem-focused history, problem-focused examination, straightforward medical decision-making) based on the lowest component, an error that would cut roughly $15 from the claim. Scenario #3: Established Patient, Face-to-Face Counseling The urologist notes "TT = 45 minutes and F/F = 30 minutes" and indicates that the discussion addressed the treatment options for carcinoma of the prostate.

Coding: Report 99215 (... a comprehensive history, a comprehensive examination, medical decision-making of high complexity) for the visit's total 45 minutes.

Why That Code? The notations [...]