Test Your Skills With These Pediatric Urology Coding Scenarios
Tip: Remember to add supplementary testing codes when needed. Pediatric urology procedures and visits are more common than you might expect. How prepared are you to code for these visits? Take a look at the scenarios below and assess your understanding of pediatric urology coding. Coding Urinary Tract Infections Scenario 1: A 7-year-old patient came into the office with complaints of urinary frequency, dribbling after voiding, and pain in their abdomen. After a thorough exam, the practitioner diagnosed the patient with a bladder infection. How can you make sure you are picking the correct ICD-10-CM code? Answer 1: The key to picking the correct code for any urinary tract infection (UTI) will depend on the location of the problem. Because UTIs most often occur in the kidneys (pyelonephritis), the bladder (cystitis), or the urethra (urethritis), you’ll need to know the specific site, and this will tell you which ICD-10-CM code is most appropriate. Your code choices include the following: Because there was no blood in the urine mentioned, and the practitioner noted it was a bladder infection, the correct ICD-10-CM code for this case would be N30.00 (Acute cystitis without hematuria). Make note: Because the N99.- (Intraoperative and postprocedural complications and disorders of genitourinary system, not elsewhere classified) codes are complication codes, they require physician documentation and confirmation of a cause-and-effect relationship between any specified procedure and complicated condition. “These types of diagnosis codes assist in describing additional conditions that may add to the initial urinary tract infection. The infection of a stoma could be a reason for the infection in the urinary tract. Make sure the documentation includes this information,” says Stephanie N. Stinchcomb Storck, CPC, CPMA, CUC, CCS-P, a longtime urology coding expert in Summerfield, Florida. Remember the difference between acute (sudden, short-term) and chronic (persistent). For instance, if the patient has acute cystitis, you’ll report an N30.0- (Acute cystitis) code; but if the patient’s cystitis is chronic, you’ll report a code from N30.1- (Interstitial cystitis (chronic)) or N30.2- (Other chronic cystitis). Keep in mind the physician is the only one who can decide whether any condition is acute or chronic. Give This Enuresis Visit Your Attention Scenario 2: A 9-year-old new patient was brought into the urology office after experiencing persistent bedwetting in recent months. After a detailed physical exam and discussion with the patient regarding any urinary symptoms, all were denied. The practitioner then ordered a urinalysis to rule out a UTI, which came back negative. The practitioner then referred the patient to behavioral therapy. How should you code this encounter? Answer: For the evaluation and management (E/M) portion of the visit, you will choose a code from 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) through 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.). For the urinalysis, if your practice views the sample under microscope, you will choose 81001 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy); but if your practice or the physician’s order only supports a urinalysis without microscopy, you will choose 81003 (… automated, without microscopy). If your tests are nonautomated, you’ll instead report 81000 (…non-automated, with microscopy) or 81002 (…non-automated, without microscopy). The ICD-10-CM code would be F98.0 (Enuresis not due to a substance or known physiological condition). Check Your Neurogenic Bladder Know-How Neurogenic bladder is a urologic condition where the nerves between the bladder, spinal cord, and brain do not communicate properly. Messages carried by the nerves tell the bladder muscles to either tighten (to retain urine) or release (eliminate urine). Depending on the nerves involved and the nature of the damage, the bladder can become either overactive or underactive. Scenario 3: A 13-year-old established patient who was recently in a car accident and suffered a spinal cord injury is now experiencing urine leakage and dribbling. After a thorough examination, urodynamics testing, and a review of their most recent X-rays and CT scan, the practitioner diagnosed the patient with reflex neurogenic bladder. How should you code this visit? Answer 3: Reflex neurogenic bladder is caused by difficulty with nerves in the upper spine as a result of the patient’s spinal cord injury. The nerve issues can lead to a lack of control over bladder contractions and loss of sensation of bladder fullness. You will first choose an appropriate E/M code for the office visit from 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making.). Note: Because the practitioner was reviewing recent X-rays and CT scans that were already in the patient’s record, this review time should be considered as part of the E/M portion. For the urodynamics testing to measure how much urine the bladder can hold and if the bladder is fully emptying, you will use 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging). For a neurogenic bladder diagnosis, assign N31.8 (Other neuromuscular dysfunction of the bladder). Remember to code the patient’s permanent injury for the payer using G95.89 (Other specified diseases of spinal cord). Stinchcomb Storck offers these three tips for fewer denials on these claims: Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
