UCR 079: FAQs - Disease v. personal history; modifier -24; data ordered prior to 1st visit - new or established

December 21, 2021

Ray and Scott discuss and answer questions from the PRS Communities.

1) I have a question regarding BPH w/LUTS; if a patient is treated successfully with a TURP, no longer having any LUTS, would the diagnosis then be BPH w/o LUTS (N40.0) or would it be Personal Hx of disease of other male genital organs (Z87.438)

2)  If a patient is in the office for the postop visit after prostatectomy, and the urologist moves on from going over postop care topics to cancer counseling(further testing/cancer surveillance/possible need for future treatment like radiation/review pathology/need for genomics/etc.), can an E/M code be billed based on time with a 24 modifier?

If so, should the 24 modifier EM code be documented on a separate note or at the bottom of the postop visit note?

If this is allowed, can you provide a sample of what the documentation should look like on the 24 modifier EM code? 

3) The practice I work for has a medical oncologist who often sees patients referred by one of urologists. A question has come up about whether the oncologist can order tests prior to seeing the pt. Aside from pt confusion about having tests ordered by someone they have not seen, I don’t think there is a problem—the initial encounter would still be a new patient visit since he has not performed a procedure or supervised a test. He could count the review of the tests he previously ordered in data since they were not counted when ordered. Is this correct?

4) Presenting Problem vs Assessment

Her presenting problem is Annual: Rec UTIs.
CC/HPI:
Follow-up recurrent UTIs, recommended management is D-mannose and Estrace, timed voiding, hygiene, copius fluids. Compliance had been suboptimal in the past but she re-reports better compliance over the last year. She's had no interval UTI's. She has no other urinary complaints.
UA today negative.
The patient's bladder is emptying adequately, with a documented post-void residual today of (mL): 7

A/P: stable rUTI on D-mannose and Estrace, timed voiding, hygiene, copius fluids

Refill Estrace, continue above lifestyle mods and d-mannose. F/U 2 years w/ PVR

Our coders said they would not feel comfortable using both assessment codes based on the above note. I’ve asked the provider to add an appended note linking the ICD-10 codes to the presenting problem, but I’m having a hard time defending the coders on this one because I understand the pathophysiology! Also, they say that they interpret this to mean the Estrace is ‘treating’ the rUTI, but it’s not……just helping to prevent one, not like an antibiotic.

I think the doc should start the note with,” Follow-up of recurrent UTI with atrophic vaginitis.” Wouldn’t that be sufficient???

5) Do I need an E/M code when I do Urodynamics procedures?

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