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Question: A uroflowmetry test was conducted in our clinic and the urologist noted, 鈥渓ower urinary tract symptoms associated with benign enlargement of the prostate鈥� and 鈥渇requency of urination鈥�&苍产蝉辫;as the diagnoses. The documentation for the uroflowmetry is: 鈥淭oday鈥檚 uroflow was reviewed with the patient. Patient was able to void 250 cc with a peak of 9.7 cc/s and the mean of 5.8 cc/s. Total flow time was 42 seconds. Flow pattern was obstructive.鈥� There are no graphs scanned in like there sometimes are, so I can鈥檛 tell if it was done with electronic equipment. How should I code the encounter?

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Answer: Based on the documentation, you should report 51736 (Simple uroflowmetry (UFR) (eg, stop-watch flow rate, mechanical uroflowmeter)) for this uroflowmetry test. Include N40.1 (Benign prostatic hyperplasia with lower urinary tract symptoms) and R35.0 (Frequency of micturition) as the supporting diagnosis codes.

Because there is no indication that the urologist used calibrated equipment, you cannot report 51741 (Complex uroflowmetry (eg, calibrated electronic equipment)).

Take note: You may want to discuss the documentation with your urologist, especially if they usually provide more detailed information and charts. This could be a chance to educate and discuss the necessary elements in the documentation that will assist you in selecting the most precise code that accurately reflects the work your urologist is performing, which can help avoid issues in the future.

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC