Urology Coding Alert

Figure out if your practice is losing money with this consultation scenario.

Reporting the wrong level of services for your urologist's E/M visits can cost your practice hundreds or even thousands of dollars every year. If you consistently downcode, you're losing money. If you consistently upcode, you're setting yourself up for possible audits and fines.

Good news: But don't worry. If you remember a few key pointers about E/M coding, you'll be sure to choose the correct level of service every time. Take a look at this sample scenario, and find out what the experts have to say about what you need to look for in the urologist's documentation to support your code choice.

Scenario: Another physician asks your urologist to provide a consultation on a patient with kidney stones. The patient has other factoring problems, namely diabetes, COPD, and hypertension. Usually based on the patient's presenting problem, you most likely will code a level-three office consultation (99243). However, because of the other problems, your urologist suggests a level-four code (99244). Even though he is not treating the diabetes, COPD, or hypertension, the urologist feels those conditions do influence his choice of therapy for the urological problem and would affect his medical decision making (MDM).

When you're assigning an E/M code for your urologist's services you need to look at the three key components of the visit: the history taken at the time of the visit, the extent of physical examination, and medical decision making.

Depending on the type of service your physician provided, you'll need to make sure the visit satisfies two or three of those elements before you choose a code. For office or other outpatient visits for established patients, you must meet the criteria for two of the three key components to bill for a specific level of care, says Christy Shanley, CPC, CPC-URO, billing manager for the University of California, Irvine, department of urology.

Despite having a higher level of MDM in this scenario, the information about the rest of the visit seems to indicate that the history and exam portions of the visit would not be higher than a "normal" 99243 visit. Therefore, even though the MDM might be higher, you would still choose the lower code, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians (UWP) and Children's University Medical Group (CUMG) Compliance Program.

Why: The documentation requirements for a level-three consultation are a detailed history, detailed exam, and low-complexity decision making. The documentation requirements for a level-four consultation are a comprehensive history, comprehensive exam, and moderate decision making. "Although a higher level of decision making is one factor in the level of service, it is certainly not the only factor," Bucknam warns.

Although the urologist is correct that documenting additional problems has an impact on his level of medical decision making, even though the physician is not treating those problems, this is not enough by itself to support coding 99244.

Bottom line: Just adding a problem list for the patient will not raise the level of MDM, says Bucknam.

Tip: For decision making itself, a patient with a new diagnosis of kidney stones and a decision for elective major surgery would qualify for moderate decision making, not low. With additional comorbidities and appropriate documentation of the impact of those comorbidities, this same situation could be a high-complexity visit. Note that elective major surgery with identified risk factors like hypertension, diabetes, and COPD is a "high" risk on the table of risk.

Caution: Without the additional history and exam (i.e., a comprehensive history and physical examination), the documented service would not support the higher level of service.

"Most patients seen in urological consultation should fit the criteria for a 99244 as a comprehensive history and physical examination are most often performed by urologists when seeing these patients for the first time," says Michael A. Ferragamo MD, FACS, assistant clinical professor of urology, State University of NY, University Hospital, Stony Brook, New York. But without adequate documentation you won't be able to properly capture level-four services.

To accomplish this you should have a good template for documenting the critical components of history and exam to help appropriately boost the level of outpatient services, Bucknam says. These templates can help ensure your urolo-gist documents all of the elements of history and exam, so that you have all of the information to choose a code.

How: There are many ways to create a "template" for your physicians. You can use actual paper forms or an electronic form in your electronic health record system, or you can provide your physicians with handy "cheatsheets" that they may carry with them. Shanley's urologists carry laminated cards in their pockets that help them to ensure they're capturing all of the proper elements of service.

What to include: "I think that a good template should really prompt the physician to put in the information specific to his practice," Bucknam says. "It should remind him to put in four elements of HPI [history of present illness], a complete review of systems (or remind him to refer to 'that patient questionnaire' that they have every patient fill out). It should remind the physician to ask about social history and family history and should lead him away from words like 'non-contributory' or 'unremarkable,' which are not good indicators of the service provided."

Additionally: "An excellent template should also remind the doctor to document exam elements that are routinely performed but not always documented," Bucknam adds. "It should remind him to list the patient's co-morbid conditions and that he personally reviewed the patient's films rather than reading a radiologist's report."