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?
Q: A 64-year-old female bilateral lung transplant recipient presents with aspiration pneumonia, hypoxia, and has immunosuppression from the drugs. How would this scenario be reported in ICD-10-CM?
Q: How would the scenario of a previous kidney transplant patient presented with sepsis due to acute pyelonephritis (E. coli), CKD, and immunosuppression be reported in ICD-10-CM?
Q: Aside from Coding Clinic , Third Quarter 2005, pp. 19–20, is there any more up-to-date advice on reporting ICD-10-CM diagnoses from physician orders?
Q: A patient who presents with complaints of progressive neck and bilateral arm symptoms is diagnosed with cervical spondylosis—worse at joints C5-C6 and C6-C7. Which ICD-10-CM codes would be reported?
Q: Can a “yes/no” query be sent based on this documentation to confirm yes, there is a postoperative hematoma, no, there is not a postoperative hematoma, or other?
Q: I’ve heard some facilities are beginning to incorporate ICD-11, even though it is not yet implemented in the U.S. How can coders help their providers transition to ICD-11?
Q: How would a coder report a coronary artery bypass graft complicated by ineffective external cardiac device insertion, subsequent removal, and intra-aortic balloon pump placement?
Q: A patient’s previously implanted Impella, a small, catheter-based ventricular assist device, was removed and replaced due to an emergency. How would we report this in ICD-10-PCS and which DRG would it lead to?
Q: Is there a hierarchy of social determinants of health codes? Is there an order of importance for us to sequence first, since only a certain number will fit on a Medicare claim?
Q: CMS recommends greater than 38°C as the upper limit temperature threshold for sepsis in the Sepsis-1 bundle, but our consulting group recommends greater than 38.3°C. What would you recommend using as the temperature threshold for diagnosing sepsis?
Q: A patient with fatty liver disease undergoes ultrasound cavitation. What diagnoses are treated using ultrasound cavitation and how is the procedure reported in ICD-10-PCS?
Q: A 4-year-old managing lissencephaly, hypotonia, and dysphagia with aspiration of secretions presents with fever and tachypnea. A chest x-ray shows right lower lobe infiltrates. Would it be appropriate to query the provider to confirm a diagnosis of pneumonia?
Q: What ICD-10-PCS codes would be used to report Stage 1 of a metatarsal resection involving Excision of nonviable tissue for diagnostic purposes and partial detachment of the fifth metatarsal?
Q: Does documentation for a drug or alcohol use disorder need to specifically state “in remission,” or is a history of drug use sufficient to classify the condition as in remission?
Q: Why isn't a secondary diagnosis of morbid obesity considered a complication or comorbidity (CC) by CMS? What obesity diagnoses are classified as CCs by CMS?
Q: What clinical criteria should coders use to support ICD-10-CM code assignment for upcoming 2023 dementia codes in category F02 (dementia in other diseases classified elsewhere)?
Q: Our coding team has been having trouble understanding how to correctly report diabetes mellitus (DM) “with” other conditions in ICD-10-CM. Can you provide some guidance on this issue?
Q: I’ve been told that if there are clinical indicators to support that chronic kidney disease (CKD) is the etiology of a patient’s hypertension, an ICD-10-CM code from category I15.- (secondary hypertension) would be assigned. Since codes from category I12.- (hypertensive chronic kidney disease) also capture CKD with hypertension, what is the best code category to be reporting from?
Q: If a physician documents a patient as HIV positive, should the ICD-10-CM code Z21 be reported? What about if they document the patient is HIV positive with an HIV-related illness—would that be reported with ICD-10-CM code B20?
Q: We recently had a patient with a history of diabetes admitted with gangrene of the left second toe. Can you review any guidance related to ICD-10-CM coding and documentation for a case like this?
Q: We recently had a patient admitted after a vertebral body tether procedure for scoliosis. Were there any changes to the fiscal year 2022 ICD-10-PCS codes for procedures related to this?
Q: Our facility has been seeing more denials lately for acute respiratory distress syndrome (ARDS), especially when both respiratory failure and ARDS are documented in the same record. How should ARDS be reported in ICD-10-CM, and which MS-DRG does this diagnosis group to?
Q: Our coding team has been having trouble reporting post-operative complications due to vague physician documentation. What language might you suggest that physicians use to clarify that the complication is indeed due to surgery?
Q: We have a patient admitted for heart failure who is also being treated for latent autoimmune diabetes of adulthood (LADA). What is LADA and how would it be reported in ICD-10-CM?
Q: We recently had a patient admitted with severe acute meningitis causing respiratory decompensation. A diagnostic lumbar puncture and mechanical ventilation were both performed during the inpatient stay. Which of these two procedures would be the principal procedure?
Q: Would telemetry and the continuation of home medications be considered continued care for a myocardial infarction (MI) or treatment when reporting in ICD-10-CM? Would this meet the definition of a secondary diagnosis?
Q: Per Coding Clinic, Second Quarter 2017, when a spinal fusion is performed without bone grafting it cannot be coded to the root operation Fusion in ICD-10-PCS. Is this advice still accurate?
Q: I’m having trouble determining how to report an acute myocardial infarction (MI) for subsequent admissions occurring within four weeks of the initial MI in ICD-10-CM. Can you walk me through the process?
Q: We have a patient admitted for COVID-19 who is now showing signs of cytokine release syndrome (CRS). Can you give our team more information on symptoms or clinical indicators for CRS as well as any ICD-10-CM coding advice?
Q: We had a patient admitted with a negative COVID-19 test, but after being retested the patient had a positive COVID-19 result. Should we query the provider whether COVID-19 was POA?
Q: We are confused about which body part value in ICD-10-PCS should be captured for an incision and drainage (I&D) of a perianal abscess of the left buttocks because the physician documented both “perianal” and “left buttocks.”
Q: When two conditions are both present on admission, both meet definition to be the principal diagnosis (PDX), and are “equally treated,” my understanding is that the condition does not have to be "equally treated" in the sense of duration/frequency. Can you provide the actual verbiage of the coding rule and explain?
Q: Was there an Excludes note change for subcategory G93.4- (other and unspecified encephalopathy) for fiscal year 2021? If so, how will it change any ICD-10-CM reporting and reimbursement for toxic encephalopathy and metabolic encephalopathy going forward?
Q: Are there any newly implemented fiscal year 2021 ICD-10-CM codes for spontaneous cerebrospinal fluid leaks (CSF)? Can you review any background and possible new codes for this disorder?
Q: Is there ICD-10-CM sequencing guidance for a patient who had a hemorrhagic stroke and then a seizure without a pre-existing seizure disorder? Would it be appropriate to report epilepsy, and are there any inclusion terms we should be aware of?
Q: What are the benefits to having coders review charts for appropriate capture of CCs and MCCs, and how can our coding team get started in this process?
Q: We have an elderly patient admitted to our hospital who is also presenting with osteoarthritis (OA) of the right knee. How can we determine primary versus secondary OA, and how would it be reported in ICD-10-CM?
Q: Our coding team is having trouble understanding the different types of chronic respiratory failure (CRF) and knowing when to suspect its presence when it’s not specifically documented by our physicians. Can you please help us with this?
Q: CMS created a new MS-DRG for chimeric antigen receptor T-cell (CAR-T) therapies in the fiscal year (FY) 2021 IPPS final rule. Which ICD-10-PCS codes group to this new MS-DRG and does it qualify for an additional new technology add-on payment?
Q: We are having trouble with a case that involves an Implantation of a cardiac resynchronization therapy-pacemaker (CRT-P) with three leads and an envelope since our facility is new to using pacemaker envelopes. How should this procedure be reported in ICD-10-PCS?
Q: When is it appropriate to report both flash or acute pulmonary edema and acute on chronic heart failure (diastolic, systolic, or other) in ICD-10-CM? What other etiologies lead to flash pulmonary edema and how do I know when to query?
Q: We have an elderly patient admitted in our hospital who is also presenting with glaucoma. Since we don’t report glaucoma on a regular basis, can you explain any background, guidelines, or tips for reporting glaucoma in ICD-10-CM?
Q: We have patients being admitted for COVID-19 and most of them have a laundry list of various manifestations and complications. Do all manifestations and complications need to be reported in ICD-10-CM?
Q: We have a patient who gave birth while admitted for novel coronavirus (COVID-19). How should this be reported and sequenced in ICD-10-CM and which MS-DRG would this be assigned to?
Q: We have a patient that was admitted with sepsis due to COVID-19 who also has human immunodeficiency virus (HIV). How should we report this in ICD-10-CM, and which MS-DRG would this be assigned to?
Q: If an inpatient is transferred before we receive a positive novel coronavirus (COVID-19) lab result, do we need to query the provider to amend the discharge summary to state “COVID-19 positive”?
Q: How should we report positive COVID-19 cases in ICD-10-CM without respiratory manifestations or any signs or symptoms and no prior suspected exposure?
Q: Is there is any guidance on ICD-10-CM reporting for screening for COVID-19? For example, a patient was admitted with pneumonia and the physician documented “COVID-19 screening completed–NEGATIVE.” Would it be appropriate to assign ICD-10-CM code Z11.59 (encounter for screening for other viral diseases) for this?
Q: We are seeing an influx of possible COVID-19 patients at our facility. How can we prepare to query for COVID-19-related documentation and coding issues that are bound to come our way due to the newness of the diagnosis?