Urology Coding Alert

Use these tips to make turning abbreviations into codes much easier

Do you know your KUB from your LKS? If not, you may need a crash course on urology acronyms. If you can't differentiate between the abbreviations in your physician's chart, you could be applying the wrong codes to your claims.

Because urology coders encounter various acronyms when reading, coding and evaluating medical charts, we take for granted that we can decipher most of the abbreviations and acronyms that we come across. But even the most experienced urology coder can benefit from a primer that outlines the most common abbreviations.

Review the following three examples and see if you can quickly figure out what the urologist did:|

1. Inserted temp. ureteral cath. Ablated renal stone via cysto. with litho. Removed cath.

2. 35 y.o. new pt. requires treatment for UTI determined by abn. C&S.

3. TURP on 65 y.o. est. pt. Dx BPH.

The answers: Translated into real-world terminology, the first example says the urologist inserted a temporary ureteral catheter and then broke up a kidney stone via a cystourethroscopy and lithotripsy. He then removed the temporary catheter.

In the second example, a 35-year-old new patient required treatment for a urinary tract infection (UTI) that the urologist diagnosed via an abnormal (abn.) culture and sensitivity test (C&S).

The third example involves a 65-year-old established patient who required a transurethral resection of the prostate for the diagnosis (Dx) of benign prostatic hyperplasia (BPH).

When in Doubt, Clarify

Medical terminology has developed over hundreds of years into an ever-increasing number of words and phrases. With the explosion of technologies over time and with the unfortunate explosion of new diseases, injuries and other types of illnesses came the newer and/or modified terms to deal with the various diagnoses and procedures.

Because of the extended disease and procedure names, physicians generated a system of communication using acronyms and abbreviations to facilitate more efficient communication among other medical professionals.

What is it? An acronym is a word formed from the initial letter (or letters) of words in a phrase or multi-word description. Contractions or abbreviations are shortened forms of a word or phrase, usually used to reduce the amount of time spent writing or dictating.

Unfortunately, in addition to being more efficient, the onslaught of acronyms has increased the possibility of error because of misunderstandings of the acronym or abbreviation. Often, the coder can discern the meaning from the usage. For example, urology coders would rarely confuse the "chief complaint" with "costochondral," although physicians often document "CC" for both of these. Because of the context of their usage, coders can usually distinguish the meaning.

Solution: If you are ever confused by a medical acronym, always ask the physician rather than guessing.

Compile Internal Acronyms

Best practice: If your office has its own internal acronyms, ask the physician to translate them and distribute the list throughout your office. Many urology offices use their own "unpublished" acronyms and abbreviations that you might know, but a newer staff member might not be able to figure them out.

The list "Let This Tool Guide You When You Encounter Acronyms" in this issue may help you to define some of your surgeon's favorite phrases, although it does not include every acronym and abbreviation that you'll encounter. There are too many symptoms, body parts, diagnoses and procedures to name, but we have left a few blank spaces at the end of the list so that if you post this somewhere in your office, you can add your surgeon's preferred acronyms as you come across them.