Urology Coding Alert

Many urology visits that should score a level-four or -five E/M code are reported as level three or four, a problem that can often be traced back to mis-interpretations of the history documentation.

To move efficiently through the history of present illness (HPI) documentation of your E/M claims, you should know what elements you're looking for and the many ways physicians can document them.

The faster and more accurately you can find these elements, the more money you save, because an insufficient HPI can be a "very expensive problem," says Todd Thomas, CPC, CCS-P, president of Thomas & Associates in Oklahoma City. HPI: Know What You're Looking For Here's a short review of the HPI elements, and tips on how to detect them and when to count them toward the history level:

1. Location is the place on the patient's body where the patient is experiencing signs and symptoms. Remember, location doesn't mean the place where the patient was when the injury occurred, but an anatomic geographic description, Thomas says. For example, "left flank pain" in the chart indicates location, but "while at work" doesn't. 2. Context means what the patient was doing when he or she experienced signs and symptoms. If a patient has an elevated PSA determination obtained shortly after a long bike ride, "after a long bike ride" serves as the context. Another example of context from a chart might be "occurred at work" or "while sitting down," Thomas says.

3. Quality describes the chief complaint or sign or symptoms. "We're looking for an adjective," Thomas says. So if the patient has a throbbing headache, "throbbing" indicates the quality. Other quality adjectives for this problem include "pounding," "shooting," "crushing" and "stabbing," he adds. 4. Timing is when the patient experiences the signs and symptoms. If the chart reads "nausea/vomiting in the morning," "in the morning" is your timing, Thomas says. Don't confuse timing and duration, he warns. Timing locates the time of day the problem occurred, and duration describes how long the patient has felt symptoms. If a patient comes into the office and says, "I've been short of breath since the morning," that statement actually describes duration because the statement reports a time period that hasn't ended. "In the morning" designates an exact time period that is over. 5. Severity describes how bad the patient's problem is. In the physician's history documentation, you will commonly see the severity reported on a scale of 1 to 10 that rates pain, Thomas says. On a handwritten chart, you might see a fraction like "7/10," he explains. Urological examples of severity of the problem or pathology include renal colic reported as very severe, 10/10, a PSA determination of 65 [...]