Urology Coding Alert

Follow these tips and guarantee proper diagnosis coding practices

Choosing the right CPT Procedure code is the first step to ensure your urologist gets paid for the work he does, but if you fail to attach the correct diagnosis code, you may be in jeopardy of receiving denials. Follow these recommendations to ensure you’re properly coding patients’ signs, symptoms and diagnoses. Watch for 4th- and 5th-Digit Requirements Correct coding requires that you code as specifically as possible. That means your physician should assign the most precise ICD-9 Code to a service. You cannot justify a service with a four-digit diagnosis code when carriers or ICD-9 requires a more specific five-digit code to describe the patient’s condition. 

“Using the fourth or fifth digit when it is required--or just when you do have that information--is an important concept to follow,” says Karen Marsh, RN, MSN, president of Kare-Med Consulting in Jensen Beach, Fla. Make sure you review the entire record when determining the specific reasons for the encounter and the conditions the physician treated, she adds.

Pitfall: Just because you have to code to the highest specificity, that doesn’t mean you can fill in or assume any information that isn’t in the patient’s medical record.

Example: When a urologist reports “benign prostatic hyperplasia,” or BPH, as the diagnosis for a transurethral resection of the prostate gland (TURP), this diagnosis alone does not clarify which ICD-9 diagnostic code would be most appropriate for the medical necessity for this procedure. Instead, a diagnosis of “BPH with obstruction” (600.01) would be more accurate and the proper diagnosis to be given by the urologist and reported by you. Unfortunately, this diagnosis may or may not be found in the medical record.
 
Don’t Avoid Signs and Symptoms When your urologist provides a confirmed diagnosis, you should always code that diagnosis instead of the presenting signs and symptoms. If, however, the urologist cannot document a definitive diagnosis, report the patient’s signs and symptoms to support medical necessity for services the physician provided.

Avoid “rule outs”: ICD-9 Coding Guidelines state that you should not report “rule-out” diagnoses in the outpatient setting. You’ll avoid labeling the patient with an unconfirmed diagnosis, and by coding the presenting signs and symptoms your urologist will still get paid for his services, even if he cannot establish a definitive diagnosis.

“Look to see if the physician has given the patient a definitive diagnosis,” says Denae M. Merrill, CPC, coder for Covenant MSO in Saginaw, Mich. “ ‘Rule out,’ ‘suspected,’ ‘probable,’ or ‘questionable’ are not codable. If there is no definitive diagnosis [...]