Urology Coding Alert

Find the trouble signs before they turn into disasters When you're auditing your charts, will you know how to recognize the signs of a major problem? Here are some red flags our chart-auditing experts have come across: 1. Billing the same code again and again. If all of your patients are level four or five, you've got trouble, but the same is true if they're all level two or three, says consultant Maxine Lewis, BA, CMM, CPC, CCS-P, with Medical Coding Reimbursement Management in Cincinnati. 2. Hospital admissions. Often, physicians don't understand how much documentation they need to provide to justify a hospital admission. You need a comprehensive history and a comprehensive examination to justify a level-two or -three hospital admission, and one of those is often missing, says Barb Pierce, coding and reimbursement director for Professional Management Midwest in Omaha, Neb. 3. Consults. Now that the rules for consults have recently changed, you need to make doubly sure you have the request for a consult documented in your files and in the requesting physician's files. 4. Canned documentation. If you have a template that you use for visits, make sure your urologist doesn't just keep reusing the same answers. If a patient comes in with pain during urination, and the doctor has already checked the box that says "no urinary pain," it won't justify the work your physician did, Lewis says. "People need to be cautious about cutting and pasting, and having too much canned documentation," Pierce says. 5. Illegible documentation. If the auditors can't read your urologist's writing, they won't bother to audit the chart -- they'll just throw it out, Lewis says. 6. Blank documentation. You choose an x-ray code by the number of views the physician performed, Lewis says. But often a physician will leave the number of views blank, and an auditor will downcode that claim to a lesser fee such as for two views, the minimum amount, she adds. Cystography (74430) requires a minimum of three views. A failure to document the presence of these views may lead to a decrease or even a full denial in payment. Also, some physicians fail to document when they interpret an x-ray, so they lose money every time. 7. Tests documented but not done. The chart may show that your urologist ordered a test, but then there's no follow-through -- for example, if the patient just decides not to go for the test. Come up with a system to make sure the patient actually has the tests after the physician orders them. 8. Time-based coding. If you're billing for counseling and coordination of care, you're entitled to bill based on time alone, if the time spent counseling [...]