Urology Coding Alert

Watch for fourth and fifth digit requirements.

If you have received a denial stating that the service your urologist provided was “medically unnecessary,” the problem is usually with your diagnosis. Protect yourself from time-consuming appeals with these important specificity requirements.

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You should always report the ICD-9 code that provides the highest degree of accuracy for the condition the urologist is treating. That “highest degree” means that you should assign the most precise ICD-9 code that most fully explains the narrative description of the symptom or diagnosis.

Rely on your ICD-9 manual’s instructions to ensure you’re listing complete ICD-9 codes. If you see a check mark with a “4th” or “5th” next to a code, ICD-9 is telling you that the code requires a fourth or fifth digit. Anything less would result in an incomplete diagnosis and a denied claim.

Pitfall: Just because you must code to the highest specificity doesn’t mean you should document or assume any information that isn’t recorded in the patient’s medical record.

Example: When your urologist reports “benign prostatic hyperplasia” (or BPH), as the diagnosis for a transurethral resection of the prostate gland (TURP), this diagnosis alone may not meet medical necessity for this procedure. Instead, a diagnosis of “BPH with obstruction” (600.01) would be more accurate and the proper diagnosis to be given by the urologist and reported by you. Unfortunately, this diagnosis may or may not be found in the medical record.

Key idea: If the ICD-9 code is not as specific as payers rules require, the claim may be rejected for lack of medical necessity and/or use of a truncated code, says Margaret Lamb, RHIT, CPC, coding expert in Great Falls, Mont.

Pinpoint Possible Pitfalls

Before sending out a claim with a three-digit diagnosis code, you should double-check the code. Three-digit diagnosis codes raise payers’ eyebrows, because there are very few ICD-9 codes that don’t require at least four digits. Payers realize this fact and are examining ICD-9 codes to ensure they’re appropriately specific.

Translation: “Medically unnecessary” can often be the result of a three-digit code that didn’t make the grade because a four- or five-digit is required.

Be Specific Now to Stay Ahead of the Curve

With the ICD-10 set to go into effect on Oct. 1 this year, you must keep your documentation specific and your superbill updated. Many offices have quite a few truncated codes on their bills, causing coders and billers to need to go back to the chart or the physician to find out what the fourth or fifth digit should be.

Remember: While ICD-9 codes are only three to five characters long, codes in ICD-10-CM can be up to seven characters in length.

When a seventh character exists (referred to as an extension and used frequently to complete a diagnosis of genitourinary trauma), it is to show episode of care, such as initial encounter, subsequent encounter, or sequelae, and other additional information.

For example, you’ll need to add a seventh digit to S30.201_ (Contusion of unspecified external genital organ, male) to identify an initial encounter (A), a subsequent encounter (D), or sequelae (S).