Outpatient Facility Coding Alert - 2018 Issue 9
Reader Question: Report E/M at Your Peril with Normal Test Results
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Article Overview
This article is a billing-focused reader question about follow-up care after a urodynamics study in an office setting. It explains the general circumstances under which a separate evaluation and management service may be considered after test review, and it is relevant to coders, billers, and urology practices handling post-test encounters and result review visits.
Why This Topic Matters
Follow-up encounters after diagnostic testing are common, and the way they are documented and billed can affect whether a separate visit is reportable. The article helps readers understand the scope of a post-test review scenario in urology and the broader documentation considerations surrounding E/M services after normal test results.
What You Will Learn
- How a follow-up visit after urodynamic testing may be framed for billing purposes
- When post-test result review is part of a broader encounter versus a separate service
- How the article relates to office-based urology testing and follow-up documentation
- What general factors affect whether a separate evaluation and management service is considered
Who Should Read This
- Medical coders
- Medical billers
- Urology practices
- Revenue cycle staff
- Compliance staff
Codes Discussed
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