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?
