Q: A 64-year-old established female patient visits the orthopedic office for ankle pain and swelling. She stepped off the curb yesterday afternoon to get the mail and missed a step, her sandal caught the edge of the curb and she rolled her right ankle. Physical examination shows notable swelling in the right ankle. Full range of motion, although patient complains of discomfort on extension and flexion. Able to weight bear. X-rays negative for fracture. Based on medical decision-making rules, what would this be coded as?
Q: What were the AMA’s goals for revising evaluation and management (E/M) services that were implemented starting in January 2021 and continued in January 2023?
Q: Why is modifier -25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service) scrutinized?
Q: What codes should a coder consider for a patient diagnosed with an eating disorder (e.g., anorexia nervosa, bulimia nervosa, and avoidant/restrictive food intake disorder)?
Q: Based on the instructions for sacroiliac joint injections, our physicians believe they can bill the injection and report imaging separately if they use ultrasound. Is this true?
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: 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: 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: 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 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?
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: 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?
