Q: A patient has unintentionally failed to take a prescribed dosage of insulin due to his Alzheimer’s dementia (age-related debility), and is admitted for initial care with inadequately controlled Type 1 diabetes mellitus. Which ICD-10-CM code(s) should we assign?
Q: Does the physician have to document the stage of a decubitus ulcer or can it be a wound care nurse? Does that person have to document stage 1 or can he or she describe the wound?
Q: Should “diabetes with gastroparesis” be coded as 536.3, diabetes with a complication code? I understood that the term ‘"with’" can link two diagnoses, but that it does not represent a cause-and-effect relationship. Can you please clarify this, and why a cause-and-effect relationship can be assumed in the term “diabetes with gastroparesis”?
Q: In ICD-10-PCS, which root operation would we report for an obstetrical delivery? Would it change for a cesarean section versus a manually assisted vaginal delivery?
QUESTION: I'd like to address our coders' questions on how to code poisoning due to bath salts. Internet research has led me to many different options: codes 977.8 (other specified drug/medicinal), 970.89 (other CNS stimulant), 969.70 (psychostimulant, unspecified), among others. What would you suggest? There don't seem to be any guidelines out there and the coding for this seems to be all over the place.
