Urology Coding Alert

Ensure you have documentation of each system -- or prepare to assign a lower code.Level-four and level-five office visits are not uncommon in a urology practice, but if you incorrectly tally the history, exam, and medical decision-making (MDM), you will miss out on the higher level codes you could report.The third element for the historical portion of an E/M service, after the chief complaint (CC) and the history of the present illness (HPI), is the review of systems (ROS) -- this portion of the E/M service trips up many coders because often they must select a lower code simply because the provider didn't document pertinent negative responses or inappropriately used the statement "all systems negative."Ensure you're properly counting your urologist's ROS with this primer to guarantee you're not overcoding or undercoding his E/M services.Differentiate ROS Levels"The review of systems is a subjective account of a patient's current and or past experiences with [...]