Renal Versus Urinary Tract?

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In one of the social media groups that I belong, a coding student posted that she completed the medical terminology course and she wanted to skip anatomy because she was ready to code.

You cannot accurately code (translate the documentation) unless you understand anatomy, physiology, medical terminology, and disease process.  It would be like translating French to German, but you’re not fluent in German.  As coders, our job is to translate.  We translate the providers’ documentation to codes that are universally understood by payers and other agencies.

I met with a coder who wanted to discuss a complete versus a limited ultrasound examination of the retroperitoneum in patients with urinary tract pathology.

According to CPT^®, if the clinical history suggests urinary tract pathology, a complete evaluation of the kidneys and urinary bladder supports a complete exam.

We discussed various signs/symptoms or conditions that would support urinary tract pathology.  According to the coder, renal failure did not support urinary tract pathology.  I paused before I asked the obvious.  Why wouldn’t renal failure support urinary tract pathology?

This was our discussion: Urinary tract is also known as the urinary system or renal system.  It consists of the kidneys, ureters, bladder, and the urethra.  If the provider documents renal failure, it is of urinary tract pathology.

This is why it is important for coders to have knowledge of anatomy, physiology, and medical terminology.  How can you code (translate the providers’ documentation) if you don’t understand the language?

Act Like a Clinician, Think Like a Coder

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In my experience as a coder, auditor, educator, and coding consultant, I’ve found that from the coding guidelines perspective, some clinicians are not compliant coders. Now, before you blow up my site, let me explain my rationale based upon my experiences.

I worked with an O/R nurse coder.  She over coded the procedures and she explained that even though the surgeon did not document all of the details of the procedure, from her experience in the operating room, she knew what he did.  I quoted the old saying, ‘if it’s not documented, it didn’t happen’ and pointed out to her that in the event of a payer audit, the documentation would not support the codes.

I encountered a physician/coding educator who stated that a chronic condition should be credited under past medical history on the E/M score sheet.  It was an opportunity for me to gain insight from the clinician’s interpretation of the documentation guidelines.  According to the physician, a chronic condition should be credited as past history because it was diagnosed in the past.  I’m not a clinician, but I’m a coder with an expert understanding of CMS’ documentation guidelines for evaluation and management services.  I referenced the documentation guidelines and quoted, ‘past history (the patient’s past experiences with illnesses, operations, injuries, and treatments)’.  I asked the physician/coding educator how a chronic condition (that was diagnosed in the past) falls into that category.  His response caught me totally off guard…he said ‘oh well, you’re not a physician’.  Absolutely, no insight gained on either side.

I audited an ER pro-fee coder who was also an ER nurse and could not match her E/M levels.  We met to review the audit results and reviewed some notes together.  There was no consistent key component where we disagreed.  According to the coder, she only looked at the presenting problem to determine the level of service – not the key components.  Our feedback session focused on the E/M Documentation Guidelines.

So, in my experience, it can be difficult for clinicians to set aside the clinical aspect of the case and translate (code) the documentation based solely upon coding guidelines.   Clinicians who step into coding have to learn and adhere to coding guidelines.

Introduction

 

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All of the stories are true.

Some of the stories are funny, but each is a lesson learned.

I look forward to sharing my experiences with you, the way my colleagues and I discuss them over coffee.

We often share experiences (without names or organizations) that help us learn to approach situations with an open mind and a good sense of humor and above all, how to maintain professionalism.

I’ve been in the medical coding industry for over 30 years, so I have a ton of stories to share.

In addition, I will sometimes go off topic to give my opinion on current medical coding issues.

This site is for you!  Feel free to like, follow, share, and leave your comments.

Visit often and share a cup of coffee!  Each week, I’ll feature a specialty coffee with a link for the recipe.  Enjoy!