Urology Coding Alert

Continuing your evolution as an ICD-10-CM coder means doing more than just staying up to date on the new code sets and guidelines. Knowing your way around a chart and surgical report is half the battle. And proper communication with your providers can’t hurt, either.

Have a look at a few essential pointers that will instantly enhance your diagnosis coding skills.

Don’t Hesitate to Contact Providers When Necessary

Suppose the physician’s dictation specifically states that the patient has a left ureteral stricture, but then the documentation refers to treating bilateral ureteral strictures, leaving the coder to wonder whether the unilateral or bilateral code applies. What should you do?

Solution: “Show the discrepancy in the documentation to the physician; once the answer is clarified, the physician should amend the chart note with the appropriate information,” says Elizabeth Cifers, MBA, MSW, CHC, CPC, of Elizabeth Cifers Consulting, LLC. “If the physician uses a scribe, educating both the physician and scribe is essential,” she adds.

If the chart documentation does not provide the highest level of specificity to assign a diagnosis code correctly, show the provider the options in the ICD-10-CM code book, so they can see the dilemma in selecting the correct code, she suggests. “Many physicians have been documenting the same way since residency and fellowship and do not realize the level of specificity that ICD-10-CM requires. Education concerning the problem is key to correcting and preventing future occurrences.”

Important: Don’t be afraid to speak up when there is a question or discrepancy in the documentation, Cifers advises. “Unless someone informs the physician, he or she may not know there is an issue.”

Avoid Suspected Diagnoses

A patient presents with pain and burning upon urination. The urologist suspects a urinary tract infection (UTI), but doesn’t offer concrete documentation supporting a UTI in the patient’s chart. What should you do?

Solution: In this case, you should only report the signs and symptoms as they appear in the medical record, which in this case include R30.0 (Dysuria).

But if there’s no ambiguity surrounding the UTI diagnosis, you’d instead code for this clinical scenario with code N39.0 (Urinary tract infection, site not specified).

Get to Know Common Acronyms

The physician examines a computed tomography (CT) scan of a patient who presents with an enlarged prostate gland. For the final diagnosis, the urologist documents “PIN” in the patient’s chart. This term is unfamiliar to the coding team, so what should you do?

Solution: In this case, it sounds like the physician has diagnosed the patient with prostatic intraepithelial neoplasia, often notated by physicians as “PIN.” PIN is a condition in which a “premalignant” neoplasm forms within preexisting benign prostatic cells.

Once the patient is diagnosed with PIN, you’ll report N42.31 (Prostatic intraepithelial neoplasia). Hypothetically, if the patient was previously diagnosed with benign prostatic hyperplasia (BPH), you will not report N40.- (Benign prostatic hyperplasia) as a secondary diagnosis since the PIN represents the next stage in the diagnostic “evolution” of the BPH.

Practice management: You may want to consider a discussion with any urologist that frequently includes obscure acronyms, or any sort of lingo that might not be easily decipherable by the coding team. Attempting to standardize dictation reports and medical terminology across urologists is a practical and efficient way of streamlining coding and billing practices. However, your team should also get to know the most common acronyms that your urologists use and keep a running list.