Urology Coding Alert

Ensuring your urologist's documentation captures every system he reviewed will help you pick the correct E/M level. One easy way to ensure that your urologist accurately documents the E/M visit components is to create a template he can follow. As mentioned in "Stop Letting ROS Conundrums Thwart Your Level 4 and 5 E/M Coding" in Urology Coding Alert Vol. 13, No. A, some physicians forget to document negative systems in their review of systems (ROS). A simple form like this can help ensure your urologist captures each and every system he reviews during an encounter. You can use this sample or tailor it to fit your practice's needs. Your urologist can use a form like the one on the next page to personally capture the ROS, or the patient may complete the form himself. Either way, have your provider reference the ROS in the dictation, and initial and date the [...]