Urology Coding Alert

Follow three steps to diagnosis coding success.

When your urologist forgets to add a diagnosis code to the superbill, that doesn’t mean you can’t bill the encounter. All you need to do is review the documentation to determine the appropriate diagnosis code you should assign to the claim.

Sticking to the following expert tips can help you successfully find the best ICD-9 codes for your urologist’s claims — without too much headache on your part.

Open the Notes When You Have to — and Even When You Don’t

Suppose your urologist hands you a superbill with the procedures circled and the diagnoses left blank.

You could ask the physician which diagnosis to report, or you could examine the documentation yourself. If your office has a policy that includes “coding by abstraction” by certified/qualified coders, then submitting charges based on what is supported (documented) in the note is appropriate, says Chandra L. Hines, practice supervisor of Wake Specialty Physicians in Raleigh, NC. In addition, the physician should be signing off on the diagnoses and the charges as part of your internal policy.

“I have permission to look at the report and put the diagnosis on the encounter form,” says Christy Shanley, CPC, CUC, billing manager for the University of California, Irvine department of urology. “If dictation is not available, then I go with form in hand back to the physician, or directly to the chart/or EMR (depending on site of service).”

Some practices choose to review the documentation and compare it against any diagnoses recorded on the superbill. This ensures that the documentation matches the code selection every time.

“Our procedure is to have physician to add the diagnosis to encounter form and make sure it is in chart,” Hines says. “The physician has to sign each encounter form. I do believe a certified coder could pull the proper diagnosis but the physician should sign off and agrees. I imagine we may be old school, but physician is responsible in the end so we should work together to make sure he dots the i’s and crosses the t’s.”

When in Doubt, Confirm With the Physician

If you are new at coding diagnoses from the urologists’ notes, you should double-check your code selections with the practitioners before submitting your claims.

Until a coder feels comfortable with the ICD-9 books and the codes used most often in their office, it’s a good idea to run the choices by a clinician. You never want to give a patient a disease or symptom they don’t have, or one more severe (or less) than what they actually have. This may also be beneficial to the physicians because if you often select unspecified codes, the physicians may then strive to better document the patient’s condition into their notes to improve the coder’s ability to choose the correct diagnoses based on the physician’s documentation.

“I strongly agree,” Hines says. “Please don’t risk it. There is such a fine line to walk here. You may not do it on purpose, but putting the incorrect diagnosis on a claim can not only put your physician practice in jeopardy but you are also putting a diagnosis on the patient’s records that is so hard to take off.”

Tip: Make sure your office creates a policy in writing that spells out what you should do when you encounter a superbill with no diagnosis listed. Some physicians prefer that you ask them for information, while most others rely on their coders to select an accurate code.

Check the Notes for Clues

Consider this example of a situation in which the coder must fill in the gap when the doctor has not written a diagnosis on the patient’s superbill.

Example: The physician’s superbill shows a level-three office visit with a patient who needs to be scheduled for an extracorporeal shockwave lithotripsy (ESWL) procedure. The form is missing diagnosis codes.

First step: You refer to the dictation, which reads: “The patient is a 43-year-old female being evaluated as a consultation at the request of Dr. Jones for back pain and painful urination. The pain started two weeks ago and has gotten worse.” The physician completes the remaining history, review of systems (ROS), past family and social history (PFSH), and physical examination.

Moving down through the chart note, you see that the patient brought with her the report and images from a kidney ultrasound and abdominal CT. The radiology procedures showed a stone in the kidney and an ipsilateral ureteral stone.

Under a separate heading, the doctor has given his assessment and plan, which states: Renal colic caused by ureteral and kidney stones, Schedule ureteroscopy and ESWL.

Next step: You look up “renal colic” in Vol. 2 of the ICD-9 index by searching “colic” and then “renal.” You find that 788.0 (Renal colic) is the most accurate code for the patient’s condition. Then, you look up “kidney stone” and “ureteral stone” by searching “calculus,” followed by “kidney” and “ureter.” You discover you should also report 592.0 (Calculus of kidney) and 592.1 (Calculus of ureter).

Based on coding for the highest known specificity of these diagnoses, you’ll report 592.0 and 592.1 as the primary diagnoses and 788.0 as the secondary diagnosis, the manifestation of the disease process.