Urology Coding Alert

Review this primer to hone your acronym decoding skills. 

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.

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. Follow these tips to be sure you aren’t missing key points or procedures in your urologist’s notes. 

When in Doubt, Clarify

If you don’t know your ADH from your BPH, you may need a review 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.

“It’s important to understand acronyms because if you do not understand what the provider is saying, you cannot code properly,” says Leah Gross, CPC, CUC, coding lead at Metro Urology in St. Paul, Minn. “It is part of understanding our specialty as a whole, and all the diseases/conditions within it ... there is potential to miscode e/m services if you do not understand everything the provider did, and there is potential to miscode a surgery if you do not know the full extent of the operation.”

Often, the coder can discern the abbreviation 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.

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 Many urology offices use their own “unpublished” acronyms and abbreviations that you might know, but a newer staff member might not be able to discern their meanings so easily.