Urology Coding Alert

Don’t let missing diagnoses stall your claim.

When your urologist forgets to add a diagnosis code to the superbill, it makes your job more difficult, but doesn’t mean you should assume the encounter is unbillable. Instead, review the documentation with an eye to detail to determine the most appropriate diagnostic code for the clinical scenario.

How do you do that? Following our experts’ tips can help you successfully find the best ICD-10 codes for your urologist’s claims so you can file on time.

Step 1: Don’t Skip the Note Check

Suppose your urologist hands you a superbill with the procedures circled and the diagnoses left blank. Unfortunately for some coders, finding themselves in that situation might not be so far-fetched.

How to handle it: You have two options at this point: ask the physician which diagnosis to report or dig through the documentation and select the diagnosis yourself.

Some practices have policies that include what’s known as “coding by abstraction.” That means certified or qualified coders are allowed to go through the chart and code the encounter based on the services the physician’s documentation supports.

Although this might seem like a scary prospect, just remember that the physician should always be checking the accuracy of the diagnoses and procedure codes before signing off on the chart for billing.

“I have permission to look at the report and put the diagnosis on the encounter form,” says Christy Shanley, CPC, CUC, finance director and billing manager for the department of urology/UC Irvine Health in Orange, Cal. “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).”

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

“Our procedure is to have our physicians add the diagnosis to the encounter form and make sure it is in the chart,” says Chandra L. Hines, practice supervisor of Wake Specialty Physicians in Raleigh, NC. “The physician must sign each encounter form. I do believe a certified coder could pull the proper diagnosis, but the physician should sign off and agree. I imagine we may be old school, but the physician is responsible in the end so we should work together to make sure he dots the i’s and crosses the t’s.”

Step 2: Don’t Shy Away From Asking the Physician

If coding diagnoses from the urologist’s notes is still new to you, don’t be afraid to double-check your code selections with the practitioners before submitting the claim.

To many practitioners’ view, that “ask” should be a requirement rather than an option.

“Until a coder feels comfortable with the ICD-10-CM book and the codes used most often in their office, it’s a good idea to run the choices by a clinician,” advises Michael A. Ferragamo, MD, FACS, assistant clinical professor of urology at the State University of New York, University Hospital and Medical School at Stony Brook, New York. “You never want to ‘give’ a patient a disease or symptom they really don’t have, or one more severe (or less) than what they actually have, by reporting an incorrect diagnosis.”

Doing such a thing – even when unintentional – can cause a ripple-effect of problems that can be difficult for the patient to reverse.

Plus: Double checking the diagnosis might also be beneficial to the physicians by encouraging them to better document the patient’s condition, making it easier for coders to choose the correct diagnoses up front.

“I definitely agree,” Hines says. “There is such a fine line to walk here, so don’t risk it. 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: Every office should have a policy – in writing – that explains what steps you should take when you a superbill with no diagnosis hits your desk. Some physicians prefer that you ask them for information, while others rely on their coders to select an accurate code. The distinction might be due to physician preference, or based on coder experience.

Step 3: Dig Deeper for Additional Clues

Every coder knows that a quick read-through of a patient’s chart doesn’t always give you the information you need for assigning the diagnosis. Here’s one more example of how to handle claims when you’re expected to help choose the best condition.

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 (50590, Lithotripsy, extracorporeal shock wave). The form is missing diagnosis codes.

First step: You review 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.

As you continue to read the documentation, you discover that the patient brought a report and images from a kidney ultrasound and abdominal CT when she came for the lithotripsy. The radiology procedures showed a stone in the kidney and an ipsilateral ureteralstone.

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: Look up “renal colic” in the ICD-10 index by searching “colic” and then “renal.” You find that N23 (Unspecified renal colic) is the most accurate code for the patient’s condition. Then, look up “kidney stone” and “ureteral stone” by searching “calculus,” followed by “kidney” and “ureter.” ICD-10 includes several diagnoses related to these conditions, including one combination code: N20.2 (Calculus of kidney with calculus of ureter).

Based on coding for the highest known specificity of these diagnoses, you’ll report N20.2 as the primary diagnoses and N23 as the secondary diagnosis, the manifestation of the disease process.