Urology Coding Alert

Find out if you need to hone your diagnosis coding skills.

Finding the proper procedure code to report for your urologist's services is only half the battle. If you don't assign an appropriate diagnosis code, your claim is asking to be denied. Urinary tract infections (UTIs), hypertension, and "rule out" diagnoses present unique challenges. Take a look at three quiz questions to see if you're up to speed on these tricky areas. Does 'Urosepsis' = UTI?

Question 1: A urologist is treating a patient in the hospital and billing initial and subsequent care with documented diagnosis of "urosepsis." Should you code 038.9?

Answer 1: No, you should not use 038.9 (Unspecified septicemia) for "urosepsis." Urosepsis means a urinary tract infection (UTI), says Denise Griffin. You have to use 599.0 (Urinary tract infection, site not specified) for "urosepsis." According to ICD-9 guidelines, "The term urosepsis is a nonspecific term. If that is the only term documented then only code 599.0 should be assigned based on the default for the term in the ICD-9-CM index, in addition to the code for the causal organism if known."

Therefore, if the physician's documentation did not specifically include the term "sepsis, systemic inflammatory response syndrome, SIRS" or the causal organism, you would only report 599.0. "The code 599.0 initially would be more specific and as the culture results come in then you could add the organism," says Monica Moore, former billing manager for Capitol Urology Associates and current credentialing coordinator for Urology Austin, PLLC in Texas.

Best bet: When you see "urosepsis," go back and ask the urologist if he is treating a simple UTI or sepsis due to UTI. If all he says is urosepsis, then code the UTI.

Key point: Code 038.9 means the patient has septicemia, which could be due to a UTI. But you must see those words -- "septicemia due to" -- to use 038.9.

Is 'Likely' A Diagnosis?

Question 2: A new patient reported to the office complaining of flank pain and gross hematuria. The patient has a history of kidney stones. The urologist performed a level-four E/M, and then ordered a CT scan. Encounter notes describe "likely" or "possible" kidney stones. How should you handle the diagnosis coding here? Should you wait for a definitive diagnosis before coding this claim?

Answer 2: You should not report kidney stones (592.0, Calculus of kidney) as the diagnosis for this E/M encounter.If a physician says that a diagnosis is "likely" you can't code that diagnosis, says Leah Gross, CPC, coding lead at Metro Urology in St. Paul, Minn.

Good news: Just because the encounter resulted in an inconclusive diagnosis, that does not mean you cannot report -- and be paid for -- the physician's services. Just make sure the documentation supports the patient's presenting symptoms.

You'll report the patient's signs and symptoms rather than a definitive diagnosis, Griffin says.

ICD-9-CM coding guidelines (Section I.B.6. and Section IV.E)  state, "Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider."

"Until the physician has ruled everything else out and they have a definitive diagnosis, they should code only the symptoms," Moore agrees.

In other words: If the urologist does not confirm kidney stones, do not consider reporting a kidney stone diagnosis. If the patient comes back for further testing that does reveal kidney stones, then you can report a stone diagnosis at that point. For the E/M encounter before a definite kidney stone diagnosis is made, you'll probably look to 788.0 (Renal colic) for the flank pain and 599.71 (Gross hematuria).

Is Benign Hypertension Inherent?

Question 3: In a laundry list note of chronic diseases and conditions your urologist describes hypertension with just "HTN." Should you report 401.1 or 401.9?

Answer 3: You have to assign the fourth digit of 9 (401.9, Unspecified essential hypertension), Gross says. To use 401.1 (Benign essential hypertension), the urologist has to document something more, such as benign.

"If no other information was given then I would use the unspecific code of 401.9 until further notice because you don't want to say its benign without more history," Moore explains.

But the real concern is whether you should list the hypertension diagnosis at all. You would list the diagnosis if the urologist documents treating the condition or if the condition affects the urological treatment. "I do not report 'outside' diagnoses if they are not related to the urologic reason the patient is in to see us, or if it is not addressed by our physician," Gross says.

You can decide whether to code the hypertension diagnosis by remembering this differentiation:

• Chronic disease: Chronic diseases treated on an ongoing basis may be coded as many times as the patient receives treatment for the condition.
• Coexisting conditions: Code all conditions that coexist at the time of the encounter only if they affect patient care or management.

Bottom line: "Reporting hypertension would be relevant if it is a contributing factor in what the patient is being treated for, such as kidney disease," Moore says. "If not and the doctor is not treating this I would not think it should be used."