Urology Coding Alert

Question: I lose audit points when I use the term "noncontributory" for any portion of the review of system element of a patient's history. What should I recommend the urologist document instead?


North Carolina Subscriber

Answer: Auditors often don't count "noncontributory" because they interpret the term to mean the bullet didn't matter. The documentation indicates that the urologist considered the review of system (ROS) element unimportant or nonapplicable. Therefore, he didn't ask the patient about the item.

Strategy: Ask your urologist to replace "noncontributory" with "no pertinent positive or negative findings." However, you may find that few physicians will write this entire phrase out.

Better method: You should encourage your urologist to use a statement that suggests he asked the patient about the bullet. For instance, a note stating, "none reported" indicates that the item mattered enough to count toward deciding an E/M code level.

 - Answers to Reader Questions and You Be the Coder contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook; and Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist practice in Indianapolis.