tci Part B Insider - 2005 Issue 41

RADIOLOGY: You Be the Coder--High Or Low? That's The E/M-Level Question For Prostate Brachytherapy

Question: I have documentation for a prostate brachytherapy patient showing that the attending oncologist took an oral history, performed a physical exam, considered several treatment options and consulted with the patient's family for a considerable amount of time. What level E/M service is required on the claim?Ohio SubscriberAnswer: Remember, the first encounter with a brachytherapy patient is usually quite involved because the physician has to rule out other treatment modalities before deciding on brachytherapy. Based on your documentation, you may be able to report this encounter as a level five E/M service. Your claim may include:• 99205 (Office...

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