Q: What terms need to be included in physician documentation to code in ICD-10-CM whether the patient’s migraine is chronic, intractable, or with status migrainosus?
Q: A physician debrides a hyperkeratotic lesion on a patient’s left foot, second toe. During the same encounter, he performs a debridement of the five toenails. Which CPT codes and modifiers would be reported for this procedure?
Q: A patient underwent a diagnostic nasal endoscopy at 10 a.m. At 7 p.m., the patient developed an epistaxis and the physician had to use some complex cauterizing techniques to control the nosebleed. How would the physician’s services in this scenario be reported?
Q: What advice can you give pertaining to clinical documentation requirements to properly report CPT codes for vaginal deliveries after cesarean (VBAC) procedures?
Q: One of our providers used a Jada device on a patient post-delivery, but I cannot find the corresponding CPT code. What is the CPT code for Jada device use?
Q: Are coders required to report a social determinants of health (SDOH) ICD-10-CM code when a CPT code for an E/M service level is based on medical decision-making (MDM)?
Q: Our coding department has a longstanding issue with physicians not presenting enough information to properly report CPT debridement services for ulcers, resulting in queries and denials. What do you recommend?
Q: What are some tips for organizations that are just starting out capturing the type of information to report social determinant of health (SDOH) diagnoses in ICD-10-CM?
Q: A physician performs a lithotripsy on a stone in the ureter or removes a stone from the ureter through a transurethral approach, then performs a percutaneous nephrostomy and treats a stone in the kidney. Would both procedures be reported?
Q: A patient with a history of prostatic hypertrophy and dysuria receives a laparoscopic prostatectomy conducted with robotic assistance. Which CPT code would be used to report this?
Q: Which CPT code would be reported for an emergency department (ED) visit for an asthma patient experiencing exacerbated symptoms and released with a prescription for treatment?
