Part B Insider - 2021 Issue 8
Reader Questions: Look at Black and White Results in This Clinical Urology Scenario
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Article Overview
This article reviews a clinical urology documentation scenario involving attempted catheter placement, bedside cystoscopy, wire-guided access, and an aborted urethral dilation attempt. It is aimed at coding professionals who need help determining which services may be reportable when a procedure is not completed as intended and how reduced-service reporting may be considered in relation to the documented work. The piece focuses on a forum-style expert response and the general coding considerations tied to the scenario.
Why This Topic Matters
Incomplete or partially performed procedures can be difficult to code correctly from the operative narrative alone. This article helps readers understand how documentation details affect reporting choices for urology bedside services and when an E/M-type service may be more appropriate than a procedure code.
What You Will Learn
- How a failed bedside urology procedure is described in documentation
- How partial completion and tolerance issues affect reporting considerations
- How reduced-service reporting may be discussed in relation to bedside cystoscopy
- When an evaluation and management service may be considered in a scenario like this
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Urology practice staff
- Physician documentation reviewers
Codes Discussed
Modifiers Discussed
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