Urology Coding Alert

Question: Our urologists normally bill office visits with post-void residual (PVR) studies. One frequent example is our providers will document that the patient comes in with BPH and urinary frequency. The provider documents the PVR residual amount along with scanning in the PVR scan into the chart. Is it necessary to document an indication for the PVR in the same document template the urologist uses for a surgical procedure? Can a provider be penalized for their documentation style even though the chart does state why the PVR was done? The medical necessity is listed in the chart and is implicated but my question is specifically on how it’s documented. Should it be listed as “This PVR is order for XYZ reason” explicitly? Or is listing the patient’s symptoms, such as “Patient came in for urinary frequency and BPH.” acceptable?

North Dakota Subscriber

Answer: While there are some best practices, there is no set template that a provider is required to use for documentation, surgical or otherwise. Federal law establishes the Conditions of Participation (CoP) in federal reimbursement programs such as Medicare and requires all institutions to maintain clinical records on all patients. The law does not clearly define what must be a part of the medical record. States generally only govern that a medical record must be created; and, occasionally, specific guidance is available to define what should be included within the medical record (e.g., medical histories, prognoses, medications ordered, etc.).

“There is no ideal format,” explains John Piaskowski, CPC-I, CPMA, CUC, CRC, CGSC, CGIC, CCC, CIRCC, CCVTC, COSC, specialty medicine auditor at Capital Health in Trenton, New Jersey and surgical coding consultant at Memorial Care Health System in Huntington Beach, California.

Caveat: The caveat to that is that, regardless of the format or template used, the medical necessity for the procedure or service must be clearly indicated in the documentation. The Centers for Medicare & Medicaid Services (CMS), other payers, and general coding rules make it clear that medical necessity is the overarching criteria for reporting any healthcare service.

CMS also states that routine diagnostic services are not payable services, Piaskowski warns. “This means that a service must be truly diagnostic in nature in order to be reimbursed. Therefore, having a documented reason for the test and a documented diagnostic finding is key to supporting the services are payable.”

Bottom line: Your urologist must create clear and complete documentation. “The key element is to link the reason for the test, the symptoms indicated on the order, or the indication for the service. The important part is to have it clearly identified in the report as the reason for the diagnostic test.

Payers do not require specific wording either. If your provider prefers brief notes or listing of the indications for the procedure, that is acceptable. If your urologist prefers documenting in a more narrative form, that will also suffice. “The goal is to have it documented to the point that any reasonable person would be able to understand why the test was being done,” Piaskowski adds.