Urology Coding Alert

Consider 9 criteria when you sit down with your audit materials

If you don't know quite where to begin when you perform your first self-audit, keep this handy reference as a guide to remind you what types of questions you should be asking yourself. For each chart, make sure you can answer the following questions and you'll know you've done a thorough job:

Does the documentation support the level of service billed?

Does the documentation support the CPT Codes and/or HCPCS Codes billed?

If the physician coded a consult, does documentation of a request from a third party exist in the chart? Does the chart contain a written consult report back to the third party?

Did the physician use modifiers correctly?

Does the documentation support the ICD-9 Codes the practice reported?

Did the physicians sign and date all entries?

Is the chart legible?

Is the name and identification number of the patient and provider on each page of the medical record and claim form?

Does the patient identification sheet include completed biographical data, including the patient’s address, employer, home and work telephone numbers, and marital status?