Urology Coding Alert

Be certain you know what to count when reviewing your claims Question: 'What's the first step in decreasing your physician's error rate in E/M audits? Answer: 'Review all notes and records that are applicable to that service. As obvious as the answer may sound, auditors will often omit vital pieces of information in their reviews, and that can lead to inflated error rates.
E/M Carries a Lot of Weight E/M services are a large part of most medical practices and can even be considered the lifeblood in some specialties. Coding accuracy and thorough documentation are critical to a practice's viability. Having a well-trained and experienced auditor is just as crucial. When performing a documentation and coding review, what records do you collect and examine? Do you look at the dictated note or the handwritten note? Patient history forms, order sheets, test results?
Gather Your Records A new patient E/M encounter generally begins with the patient filling out a history form. The volume of information obtained from the patient will vary from office to office or specialty to specialty. The patient's medical history and social and family histories could be covered. There may be a review of systems (ROS) that is problem-oriented or greatly detailed and considered "complete." For the physician to receive credit, she will need to indicate that she did, in fact, review the information. A co-signature and date on the form(s) would qualify, and/or a statement made within the progress note referencing the history form would suffice, too. As long as the healthcare provider creates some type of direct link to the source document, the auditor should give credit. For subsequent or hospital visits, when your urologist updates a patient's history form, give him credit for the information it contains as long as he makes a notation to that effect. But updating a history form simply to inflate the documentation content for billing purposes would be inappropriate. The past medical, family and social histories, as well as the ROS, should be relevant to the nature of the presenting problem. Electronic medical records (EMR) have changed the world of medicine over the past few years. But for those physicians still using traditional transcription or who have yet to transition to a fully automated EMR, the handwritten note continues to be essential to the audit. At first glance, a handwritten note might seem scanty -- maybe just chicken scratch made by the physician as he interviews and examines the patient -- but it just might contain a missing element that could end up making a difference in code selection. Handwritten notes can be found in obscure places in the chart, and this is especially true of an inpatient chart. The [...]