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?
