Q Some of our physicians are billing for a level 2 or 3 counseling visit when they discuss the test results of sonohysterograms immediately after the procedure. Is this legitimate, or is patient counseling included in the sonohysterography codes?
A The sonohysterography codes, both for the injection of the saline (58340) and the radiologic supervision (76831), only include obtaining informed consent or telling the patient what to expect during the procedure, not patient counseling. Therefore, the physician also may bill for an E/M service, which encompasses a discussion of the results and appropriate follow-up. In addition, include the modifier-25 to indicate that the counseling was a significant, separate E/M service that took place on the same day as the procedure.
This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.