Q: How can queries play a role in clarifying malnutrition and cachexia diagnoses while ensuring the patient’s condition is reflected in the medical record accurately for proper coding?
Q: How should a coder handle the documentation and coding of a fragility fracture when the underlying cause, such as osteoporosis, has not been clearly established?
Q: What clinical factors distinguish acute skin failure from a pressure injury, and how should the two conditions be approached from an ICD-10-CM coding perspective?
Q: When coding endoscopic procedures, some CPT codes have multiple procedures bundled in a single code. How do coders report when one of the procedures isn’t done?
Our experts answer questions on distinguishing cachexia from malnutrition for accurate coding, navigating clinical uncertainty and coding for acute skin failure and pressure injuries, and unpacking the fifth universal definition of MI.
Q: What are the key characteristics of cachexia versus ASPEN-defined malnutrition, and what ICD-10-CM codes are available for reporting each condition?
Q: What are some red flags associated with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) that might trigger payer audits?
Our experts answer questions on identifying cerebral edema and brain compression in the medical record, recognizing when documentation drives diabetes coding, and utilizing photos in queries.
Q: When reviewing neurologic cases, what documentation clues, imaging findings, and treatments should coders and CDI specialists look for to identify potential cerebral edema or brain compression diagnoses?
Q: A patient is in the office today being seen for abdominal pain six days post-op of removal of a benign tumor. After ultrasound, cholecystitis is diagnosed and the patient is scheduled for surgery the next day. Is it appropriate to use modifier -24 in this case?
Our experts answer questions on navigating sepsis coding in an era of conflicting clinical criteria, evaluating abnormal renal function in the clinical record, and addressing payer denials that passed on queries.
Q: When abnormal renal function is documented without a clear diagnosis, what clinical indicators should coders review to determine whether a provider query is warranted?
