Q: Consider patients who are admitted with cellulitis and have type 2 diabetes mellitus with no neuropathy or elevated glucose levels. Should coders query the provider to clarify if the cellulitis is caused by the diabetes, or should such a query only be sent if a patient has other complications of diabetes such as hypoglycemia or neuropathy?
Q: How do I know when to use CPT code 26370 vs. 26356, for a finger tendon repair? Is it based on whether there is an intact flexor digitorum superficialis (FDS) tendon, or whether the cut or laceration of the flexor digitorum profundus (FDP) tendon was in Zone II?
Q: Video colonoscope was advanced through a patient’s rectum to the cecum where there was normal-looking mucosa throughout. The patient had scattered diverticula in the sigmoid colon and a 6-mm sessile polyp in the proximal rectum that was removed completely by hot biopsy technique. Surgeon documented to await pathology report. How would this operative note be reported in ICD-10-CM and ICD-10-PCS?
Q: What ICD-10-CM code should we report for a periprosthetic fracture due to an injury? Do you use the S codes for a traumatic fracture with a secondary code for replacement, or do you select a code from the M97 (Periprosthetic fracture around internal prosthetic joint) category?
Q: A patient is in the postpartum period after delivering a healthy baby girl. She developed diabetes mellitus during the pregnancy. She is being treated with Metformin, an oral hypoglycemic drug. How would this situation be reported in ICD-10-CM?
Q: What are some of the common documentation pitfalls or missteps related to pediatric malnutrition? And what can CDI specialists do to address them proactively?
Q: A physician documented metabolic encephalopathy on a postoperative patient who was sedated on a vent, but because there were not documented responses while on the vent, I was unable to clinically validate the encephalopathy while the patient was sedated on the vent. How would a coder query this diagnosis for validity?
Q: Is it appropriate to code metabolic encephalopathy related to alcohol withdrawal or alcohol withdrawal delirium? And if so, how do you successfully defend against denials?
Q: A patient presents with a chief complaint of thoracic intrinsic spinal cord lesion causing back pain, left lower extremity sciatic-type pain, and foot drop. An MRI of the thoracic spine revealed a T11-T12 spinal cord lesion consistent with a cavernous malformation. Which ICD-10-CM codes would be reported?
It is important for both coders and providers to understand that they can report critical care along with other services such as ED E/M and CPR. Hamilton Lempert, MD, FACEP, CEDC, answers questions about the proper ways to do so, as well as the importance of doing so. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
Q: A specialty society's fact sheet offers guidance for determining E/M level when an ICD-10-CM social determinant of health code affected the diagnosis or treatment. What is Medicare's policy on this?
Q: A 64-year-old female patient who has a bilateral lung transplant presents with COVID-19 (reason for admission) with acute respiratory failure. She also has immunosuppression from drugs. How would this scenario be reported in ICD-10-CM?
Q: Should signs, symptoms, or unspecified ICD-10-CM codes (e.g. M54.50 [low back pain, unspecified]) be reported when the condition (e.g. M51.36 [other intervertebral disc degeneration, lumbar region]) is also reported on the same outpatient encounter?
Q: A 64-year-old female inpatient has hepatocellular cancer with an orthotropic liver transplant with bile duct obstruction and is immunosuppressed due to drugs. Which ICD-10-CM codes would be reported?
Our experts answer questions about querying a metabolic encephalopathy diagnosis and documenting the start of mechanical ventilation if a patient is intubated in another ED.
Q: A patient has acute renal failure due to dehydration, a history of Type 1 diabetes mellitus causing end-stage renal disease, a kidney transplant two years ago, and chronic kidney disease stage 3a, immunosuppressed by their drugs. How would this be reported in ICD-10-CM?
