Urology Coding Alert

Stress legibility as well as detailed notes.

Every coder knows that documentation is the key to select the right code, whether it is a procedure code or a diagnosis code. If your provider doesn’t give you complete, accurate details, you can’t accurately depict his work and the patient’s condition using codes. 

Now that you have an extra year to get ready for the ICD-10 implementation, set to take place on Oct. 1, 2015, you can take time to help your urologist improve his documentation. Helping the doctor understand how critical his notes are can ensure you earn all the pay he deserves and avoid audit problems — or even fraud charges. Start with these seven steps. 

ICD-10 and CPT® Require Details

Whether assigning a diagnosis or procedure code, you’ll need specific information from the operative or encounter note to choose the right code.

Under ICD-10, physicians will need to beef up their documentation, according to Arlene Maxim, RN founder of A.D. Maxim Consulting, A.D. Maxim Seminars, and The National Coding Center, in Troy, Mich. “Documentation will make or break this process,” says Maxim, because ICD-10 will require a higher degree of specificity. 

Reporting surgical procedures also requires detailed information. For instance, to choose the correct procedure code for a biopsy, you must know if the surgeon performed an open excisional biopsy or a percutaneous needle core biopsy, and whether radiological imaging or a localization procedure was used. When coding major surgical procedures, you must also know if the surgical procedure was performed via an open or laparoscopic approach, or both, and if your urologist used robotic technology.

Documentation is key: Clinical documentation is the foundation of every health record, according to Dorothy D. Steed, CPC-H, CHCC, CPUM, CPUR, CPHM, ACS-OP, CCS-P, RCC, CPMA, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CPAR, AHIMA Approved ICD-10 Trainer, an independent healthcare consultant and educator in Atlanta, Ga. 

Clinicians may collect documentation only once, but others will use it many times, said Steed during the recent audio conference “Clinical Documentation Improvement” sponsored by The Coding Institute affiliate AudioEducator.com. The “coder needs high quality documentation to ensure coding quality and accuracy,” she said.

Check These Documentation Criteria

Here are seven criteria for quality documentation. Make sure your urologists’ record keeping will pass muster with these expert tips.

1. Legibility: Documentation should be readable and easily deciphered, but often handwritten documentation isn’t, Steed cautioned. Complete and legible entries provide protection for providers. But illegible entries in a medical record may cause:

• Misunderstanding of a patient’s condition
• Jeopardized reimbursement
• Denied payment
• Loss of legal appeals.

Remember: Legibility doesn’t just refer to handwriting — an electronic record isn’t “legible” if the words filled into blanks do not make sense, even if you can easily read the printed words.

Also note that a legible note includes being able to read the name and title of the physician completing the documentation.

2. Reliability: The documentation should support the rationale for the diagnosis and medical necessity for the procedure. If it doesn’t, you should question the reliability of the note and ask the urologist for clarification.

Most denials and down coding occur when at least part of the documentation doesn’t support the codes you report.

3. Precision: Clinical documentation must be exact, and strictly defined. Make sure your surgeon uses terms precisely, such as using “biopsy” to refer to tissue samples taken for diagnosis with no attempt to remove an entire lesion and reserving “resection” or “excision” for procedures that extract all or part of an organ or region of diseased tissue.

4. Completeness: Good documentation fully addresses all necessary items, including complete patient information, procedure description, diagnosis statement, and physician identification. 

5. Consistency: Documentation shouldn’t be contradictory. If there are conflicting statements in the record, such as the use of the term “biopsy” in an operative note that identifies and requests a review of specific margins, you need to review what procedure, biopsy or excision, was actually performed. Coding for a biopsy when the surgeon actually performed an excision or resection could cost your practice. 

6. Clarity: Documentation should not be ambiguous. Operative reports using vague descriptions such as “closed surgical site” instead of a specific statement such as “performed a layered closure” may not support the services your urologist provided.

7. Timeliness: Documentation must be up to date to help ensure optimal patient treatment.