ICD-10 Documentation for Major Urological Disorders

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ICD-10 Documentation for Major Urological Disorders With the ICD-10 implementation date (October 1, 2015) approaching fast, it is time to encourage the practice of using standardized urology documentation according to the new system. The new coding system comprises around 70,000 codes and allows for increased specificity in many areas. Detailed documentation is vital to code the procedures accurately. You should document the details about laterality, severity, location, etiology and visit (initial visit, subsequent visit and visit for sequelae of the condition) as there are different reimbursement codes specified for all these details. Let’s take a look at ICD-10 documentation details for major urological disorders. Transcription of the medical terminology has to be perfect so coding can be effective.

Acute Kidney Failure You should document etiology known or suspected as acute tubular, cortical or medullary necrosis since separate codes are there for all these conditions. It is also required to specify whether it is a post-procedural or posttraumatic condition. As the codes are very specific, make sure that you are clear on your intended diagnosis. If you report ‘acute renal insufficiency’, it will result in unspecified kidney failure code.

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Chronic Kidney Disease (CKD) It is required to document the severity of CKD as there are separate codes for Stage 1, Stage 2 (mild), Stage 3 (moderate), Stage 4 (severe), Stage 5 and End Stage.

You should well-document etiology as well such as Diabetic CKD or Hypertensive CKD.

Cystitis First of all, you should document whether hematuria is present or not as separate codes are there for with and without hematuria. Specify the type of cystitis such as acute, chronic, interstitial, trigonitis or other since there are different codes for each of these types and unspecified cystitis. In the new coding system, additional codes are used to identify infectious agent along with code used to specify the condition of cystitis. Therefore, you should also document the organism if known or suspected.

Urethral Stricture This medical condition affects men more than women and if the affected patient is male, you

should

document

the anatomical

site such

as Meatal, Bulbous,

Membranous or Anterior as each of them has a unique code. Etiology has to be reported as Posttraumatic, Postinfective, Postprocedural, other cause or unknown.

While documenting etiology, specify whether male or female in the case of Posttraumatic, Postinfective and Postprocedural

condition. If

a

female is in

posttraumatic condition, specify whether it is due to childbirth.

Urinary Tract Infections (UTI) Document the specific site of the UTI, if known such as bladder, urethra or kidney. If UTI is associated with a device such as Foley catheter or cystostomy tube, you should indicate this clearly using the words ‘due to’ or ‘secondary to’. It is also required to document causative organism if known or suspected such as E.coli or Candida.

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Urosepsis Do not use the term ‘Urosepsis’ while documenting for ICD-10 as there is no code for it. Be very clear on your intended diagnosis and make sure your intended diagnosis is UTI, bacteremia or sepsis/severe sepsis and document it accurately.

Most healthcare experts expect a dip in revenue in the first few months after the ICD-10 implementation. It is because they assume that urology groups may take time to learn the specific codes which will cause a significant delay in producing the documentation and charts that ensure the selection of proper reimbursement codes.

This may cause delay in reimbursement claims and revenue loss. If urology practices follow standardized ICD-10 documentation as early as possible, they can reduce the impact of future revenue loss to a great extent.

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