Urology Coding Alert

Draw on the answers you need for accurate coding

What you don't know can hurt you - especially your coding. When you need more information from a urologist, don't hesitate to ask. But for the quickest, most helpful and correct results, remember these tips throughout the coding process.

Do: Assign codes clearly and consistently, as supported by existing physician documentation. Know that you've done your job before you ask the doctor for further clarification - you don't want to sort through your own errors on top of incomplete chart information.

Do: Assess the urologist's documentation to make sure it supports the codes you've chosen for the claim.

Do: When you see conflicting or ambiguous data in the patient's record, consult the urologist for more documentation and explanation before you assign codes.

Do: Advocate specificity of documentation.

Do: Ask for resequencing and/or inclusion of diagnoses and procedures, when it's necessary to make the chart clearer.

Don't: Misrepresent the patient's clinical condition by assigning incorrect codes or reporting diagnoses or procedures that the urologist's documentation doesn't support. Your objective is to report the clinical information correctly, not to maximize reimbursement.

Don't: Alter codes to misrepresent the patient's diagnoses or procedures.

Don't: Include or exclude certain codes based on what you know the possible payment or insurance coverage to be.

Information provided by Margaret Gambill, RHIA, CCS-P, with BKD Health Care Group, who presented on physician querying techniques at a recent AHIMA clinical coding meeting.