Urology Coding Alert

Carefully read the physician’s notes to extract ICD-9 Codes

In a perfect coding world, our physicians would support the coders’ efforts by providing CPT Codes for all services rendered, properly document these services, and then link their procedures to supporting ICD-9-CM codes. But let’s have a reality check -- it rarely works like that. 

Hopefully your physicians realize the importance of coding and have taken a more active role in this function. The amount of participation is going to vary greatly, so we as coders need to be able to fill in the gaps. The gaps may be simply checking for bundling edits and solid linkage between your procedures and diagnoses but, unfortunately, may often mean combing through lengthy office documentation and complicated procedure notes to assign all codes and diagnoses on your own. 

The provider has hired you for your coding expertise and trusts that you will do as much background work as possible so that when you do have to seek clarification, the physician will be able to determine, due to the documentation, why you had to ask what you did. This interaction allows you to learn and make notes so you are prepared the next time the same situation presents itself, and the providers will learn where their documentation is deficient so they can then supply us with all information needed to make the process a smooth one -- from rendering the service, to having the claim go out the door in a timely fashion so they can be paid for what they are doing. 

Rule Out Ambiguity

You may also encounter blank superbills along with documentation that mentions tests to “rule out” certain conditions. But because you can never report a diagnosis listed as “rule out,” you’re up a creek if you can’t pin down an accurate diagnosis.

Never Submit Diagnosis Based on a Guess

Use the internet, medical dictionaries, etc., for resources, but never guess. When in doubt, ask your provider. Your ICD-9-CM selection is going on record for this patient and may affect his ability to get medical insurance in the future.

The best thing you can do is to read through and familiarize yourself with the coding guidelines printed in the front of your ICD-9-CM book. There is a wealth of information there, and should you be questioned on your code assignment you should be able to cite from the guidelines how you arrived at your selection. These are the official guidelines that have been approved by AHA, AHIMA, CMS and NCHS, and adherence to these guidelines is required under HIPAA.