Urology Coding Alert

Reader Question:

Skip E/M for Second Visit to Get Test Results if Results are Normal

Published on Thu Jul 12, 2018

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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?

New Mexico 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 regiment 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, you can report the appropriate E/M code associated with that condition.