Urology Coding Alert

Encourage detailed documentation for the most specific diagnosis code assignment. 

Cystitis is probably a common word in your urology practice. But seeing “cystitis” doesn’t lead you to one single diagnosis code in ICD-9, and it won’t get any simpler in ICD-10 either. You’ll still need more details from your urologist to choose the proper code. 

Stick to the Documentation

In ICD-9, you need to know the specific type of cystitis the patient has and often the specific location of the inflammation and/or infection. 

When ICD-10 goes into effect on Oct. 1, 2015, you’ll still need to look for the same details about the cystitis type and location. However, you will also need to scour the documentation to see if your urologist notes that the patient also has hematuria. If the patient does, your coding will change. 

Good news: Your urologist is likely already documenting the details you’ll need to choose the right code. But if he isn’t, be sure to explain that accurate ICD-10 coding will require very specific details and encourage him to start providing you as much information as possible in his notes. 

Review the table below to see your ICD-9 codes and the ICD-10 options you’ll turn to next year.