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 form.

"I don't feel that the doctor has to capture the ROS, but do feel that he needs to review it with the patient to determine the level of care," says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia.

Important: Patient-completed ROS templates may be OK, but ask your urologist to make his documentation specific to each patient. Also, be sure your urologist documents that the ROS was reviewed with the patient by noting any additional pertinent information.

Pointer: "When a practice is under audit by an insurance company and documentation for E/M codes is requested theforms the patient filled out, including the ROS, should be included to gain credit for the ROS unless the physician takes the visit and dictates a comprehensive overview of what is contained in the chart," says Nicole Martin, CPC, manager of the medical practice management section of the Medical Society in New Jersey in Lawrenceville.