Urology Coding Alert

Question: What documentation must be included in the office note when a PVR test is done? We recently had a note with only the post-void amount – not actual test result that also included the pre-void amount.

Maryland Subscriber

Answer: A simple statement such as, "PVR; ____ ML" amount should be sufficient when backed by the urologist's documentation. Also indicate the method of obtaining the PVR (post void residual), whether it be via sonography or catheter drainage. Many payers have an LCD (local coverage determination) for the test that lists applicable diagnoses. Check your LDC to verify that you are in line with its guidelines.

Appropriate ICD-10 diagnoses include R33.8 (Other retention of urine), R39.15 (Feeling of incomplete bladder emptying), and R33.0 (Drug induced retention of urine).