Coding is the process of identifying descriptive terms and codes for diagnoses and medical services. These are generated from interacting with patients and other healthcare providers. This information is gathered and then organized in alpha and/or numeric order that can then be used for charge submission, performance measurements, and data collection for emerging technology, services, and procedures. Under the Health Insurance Portability and Accountability Act, The Department of Health and Human Services designated the International classification of Diseases and Current Procedural Terminology as the national standard code sets for healthcare professional services and procedures.
Although daunting medical billing methods are one of the most critical functions of your Urology practice. Urology Medical coding and Urology medical billing both are terms used to refer to a set of standards and guidelines that are used to characterize what has been treated and how it was handled. Among the many aspects of your medical practice documentation is key. Accurately recording then transcribing that documentation into the proper codes, modifiers, and extensions help create a seamless function of proper revenue stream for the practice by reducing claim rejections and denials. Denials however can be one of the many issues Urology practices face and failing to take safeguards to prevent denials can be costly to your practice.
Stay on top of Urology coding updates
Yearly the American Medical Association (AMA) makes new changes to the Current Procedural Terminology (CPT) codes, and it is vital to make sure your practice stays current on the most advanced coding updates. Coding is an integral business skill that an Urology must develop and cannot be reiterated enough. Coding is the systematic way you transcribe what you treated and how you treated in order to be paid.
Documentation is critical to your Urology practice and correctly interpreting this information and transcribing it into proper codes cannot be stressed enough. We will begin with Evaluation and Management(E&M) services new and established patient visits and consultations. Remember moving forward coding is rule based. Therefore, E&M documentation has strict and specific criteria that determine the level of visit performed, including the location that the service is performed. E&M service has three key components: history, physical examine, and medical decision making. The guidelines for each of these areas are found in the Current Procedural Terminology (CPT) codebook. The detail included in the note needs to match the level of E&M service reported. The physical examination must be performed and documented by the individual recording the visit. It is recommended at this time labs and tests are documented in the medical decision-making portion. Lastly, the assessment and plan should be thoroughly summarized. This area of CPT coding is most complex.
A modifier is a 2-digit code that furthers defines a CPT code. Modifiers are used to communicate additional information to the payer and are applied for many reasons including but not limited to a return to the operating room for a related procedure or an E&M service that includes the decision for surgery. Modifiers are designed to be used with either an E&M or a procedure code. Memorizing all the possible modifiers is difficult, but you should be aware of all the different reasons that a modifier may be needed to complete a code. When put to use properly, modifiers can bring accuracy and detail to the record of the transaction.