Q: A few days into the patient’s stay, an order for a Foley catheter was placed for incontinence and around the same time the physician documented a urinary tract infection (UTI). Would it be appropriate to query the physician regarding the relationship of the UTI to the Foley? Our infection control department caught this but we did not. I am concerned about this for two reasons; first, I worry about writing a leading query and second, whether the UTI could be considered a hospital-acquired condition (HAC) if additional documentation isn’t provided.
Q: If the clinical impression is physical assault, vomiting, blunt injury to abdomen, and head injury with loss of consciousness, can I code the history of hypertension, diabetes mellitus, headache, bipolar disorder, and depression?
Q: I read that CPT ® code 20680 (removal of implant; deep, e.g., buried wire, pin, screw, metal band, nail, rod, or plate) is commonly used for deep hardware removal. What would be the proper code for removal on one screw that has already made its way out, is not under any muscle, and is easy to visualize?
Q: We had a question regarding documentation in a record of SIRS due to acute peritonitis without sepsis. Our critical care physician on that case called it severe sepsis as well. What would you do in a situation like that?
Q: My office often has denials of evaluation and management (E/M) visits with our OB patients when using HCPCS modifier -GB (claim being resubmitted for payment because it is no longer covered under a global payment demonstration). Would coding with V22.2 (pregnant state, incidental) as a secondary diagnosis possibly alleviate this issue?
Q: I’m in a little debate: Does documentation of the patient’s body mass index (BMI) need to come from an ancillary clinician, like the dietitian or nurse? I thought that we could use such ancillary documentation for clinical indicators supporting our physician query, but the treating physician needed to document the BMI. Can you help clarify this for me?
Q: I have been told to use the general surgery CPT ® codes in the 20000 series for reporting excisions of sebaceous cysts when the surgeon must cut into the subcutaneous layer. I don’t agree with this, since the 20000 codes do not give ICD-9-CM code 706.2 (sebaceous cyst) as a billable diagnosis code. Because a sebaceous, epidermal, or pilar cyst begins in the skin and may grow large enough to press into the subcutaneous layer, I think we should report an excision code from the 11400 series, and if need be, the 12000 codes for closure.
Q: A patient is admitted with a high white blood count, tachycardia, tachypnea, and chills. The blood culture shows positive for methicillin-resistant Staphylococcus aureus (MRSA). The attending physician documents MRSA sepsis in the progress notes. Antibiotics are changed based on the blood culture and the patient is treated with appropriate antibiotics. Due to poor vascular access, a central venous catheter (CVC) is inserted and antibiotics are infused through this access. The patient responded slowly to treatment and CVC access becomes red and inflamed. The catheter is removed and cultured. The physician documents this to be an infection due to MRSA. What’s the diagnosis code for this?
Q: Our physicians document a diagnosis of pneumonia but do not normally make a specific connection with the patient's ventilator status, even when this is obvious from the record. For example, the patient's been on the ventilator support immediately prior to the diagnosis. Can I report this as ventilator-associated pneumonia in ICD-10-CM without the documentation specifically connecting the conditions?