Q: A patient with severe emphysematous bronchitis is hospitalized due to acute RSV bronchitis. He is noted to have a history for cerebrovascular accident with residual oropharyngeal dysphagia occurring in the past year and on day three of the hospitalization, he aspirated some of his breakfast during an episode of severe coughing. The patient’s RSV swab is now showing negative, so viral bronchitis is considered resolved, but patient continues to require treatment for secondary aspiration pneumonia, which is their main concern at this point, as well as acute hypoxic respiratory failure. He will require oxygen continuously. How would this diagnostic note be reported in ICD-10-CM?
Q: A female patient previously had an inpatient stay due to severe enteritis secondary to the use of Keytruda for colon cancer that she was diagnosed with six months earlier. While she has had positive results to the medication, she presented to the ER last week due to severe abdominal bloating and cramping with diarrhea and stools with large amounts of mucous. She was dehydrated and hypokalemic upon inpatient admission and has a history of depression. Her discharge note indicates that her potassium levels and dehydration are normalized. How would this encounter be reported in ICD-10-CM?
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: A frail 74-year-old female presents with severe shortness of breath and hypoxia. She has a known history of smoking two or more packs per day for the past 40-50 years and has a complex history of chronic obstructive emphysema, centrilobular emphysema, bronchiectasis, and pulmonary hypertension. Her current hospitalization is due to MRSA pneumonia with planned discharge to home health for continued care. How would this diagnostic note be reported in ICD-10-CM?
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: An elderly male patient has a rectal fistula with an abscess requiring complex packing of the wound. The most recent wound documentation reports “complex persistent rectal fistula with underlying abscess present, cultures show positive for E. coli and Klebsiella.” The patient will be administered daily IV antibiotics via a PICC line that has been placed. How would this encounter be reported in ICD-10-CM?
Q: Patient presents with a chief complaint of persistent cough for 10 days with occasional mucus. She has a history of chronic asthmatic bronchitis for many years; is quite frail, reporting decline in energy and activity tolerance; was a smoker until about five years ago; and suffers chronic smokers’ cough and centrilobular emphysema. Past medical history includes heart failure, hypertension, and pulmonary hypertension. How would this diagnostic note be reported in ICD-10-CM?
Our experts answer questions on coding COPD, smokers’ cough, and rectal fistulas in ICD-10-CM as well as provide recommendations for addressing malnutrition denials depending on the diagnosis criteria used (GLIM or ASPEN).
Q: A 65-year-old female has been on Effexor for major depressive disorder for three months and went to her healthcare provider due to tachycardia and palpitations along with mild muscle cramping. It was found that she had accidentally been taking double her prescribed dose due to misunderstanding the instructions. It is reported that she developed serotonin syndrome resulting from toxicity and was also diagnosed with mild hypertension (138/88) due to the serotonin syndrome. How would this encounter be reported in ICD-10-CM?
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)?
Our experts answer questions on the new ICD-10-CM serotonin syndrome code, key takeaways for documenting and supporting malnutrition diagnoses, and appropriate circumstances for reporting codes from ICD-10-CM subcategory E66.8- (other obesity).
Q: A patient presents with exacerbation of COPD complicated by positive COVID-19 with COVID-19 pneumonia and superimposed MRSA bacterial pneumonia in the setting of chronic bronchitis due to smoking, severe persistent asthma (not currently in exacerbation), and left lower lobe lung cancer in remission following a lobectomy one year ago. Patient continues to smoke cigarettes. How would this diagnostic note be reported in ICD-10-CM?
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: Consider patients who are admitted with cellulitis and have type 2 diabetes mellitus with no neuropathy or elevated glucose levels. Should coders query the provider to clarify if the cellulitis is caused by the diabetes, or should such a query only be sent if a patient has other complications of diabetes such as hypoglycemia or neuropathy?
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: Video colonoscope was advanced through a patient’s rectum to the cecum where there was normal-looking mucosa throughout. The patient had scattered diverticula in the sigmoid colon and a 6-mm sessile polyp in the proximal rectum that was removed completely by hot biopsy technique. Surgeon documented to await pathology report. How would this operative note be reported in ICD-10-CM and ICD-10-PCS?
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: A patient is in the postpartum period after delivering a healthy baby girl. She developed diabetes mellitus during the pregnancy. She is being treated with Metformin, an oral hypoglycemic drug. How would this situation be reported in ICD-10-CM?
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: A physician documented metabolic encephalopathy on a postoperative patient who was sedated on a vent, but because there were not documented responses while on the vent, I was unable to clinically validate the encephalopathy while the patient was sedated on the vent. How would a coder query this diagnosis for validity?
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 patient presents with a chief complaint of thoracic intrinsic spinal cord lesion causing back pain, left lower extremity sciatic-type pain, and foot drop. An MRI of the thoracic spine revealed a T11-T12 spinal cord lesion consistent with a cavernous malformation. Which ICD-10-CM codes would be reported?
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: A 64-year-old female patient who has a bilateral lung transplant presents with COVID-19 (reason for admission) with acute respiratory failure. She also has immunosuppression from drugs. How would this scenario be reported in ICD-10-CM?
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?
Q: A 64-year-old female inpatient has hepatocellular cancer with an orthotropic liver transplant with bile duct obstruction and is immunosuppressed due to drugs. Which ICD-10-CM codes would be reported?
Our experts answer questions about querying a metabolic encephalopathy diagnosis and documenting the start of mechanical ventilation if a patient is intubated in another ED.
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?
Lynn Anderanin, CPC, CPB, CPMA, CPC-I, CPPM, COSC , covers FAQs she has received, specifically about CPT reporting for arthrodesis, acromioplasty, arthroplasty, arthroscopy, and spinal decompression procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: How would a coder report the scenario of an unmedicated diabetic patient with diabetic renal nephrosis and out-of-control blood sugar during an encounter?
Our experts answer questions about ICD-10-CM coding for diabetic patients with hyperglycemia, CPT documentation requirements for wound sizing, and more.
Our expert answers questions about ICD-10-CM sequencing for renal complications after a transplant, reporting malignant neoplasms in transplanted organs, and more.
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?
Lynn Anderanin, CPC, CPMA, CPPM, CPC-I, COSC , answers frequent questions she receives from providers pertaining to physician coding for CPT orthopedic services. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
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?
Our experts answer questions about CPT/HCPCS codes for reporting obesity counseling, HCPCS reporting for social determinants of health assessments, and more.
Our experts answer questions about payer criteria for chronic kidney disease diagnoses, ICD-10-CM documentation requirements for reporting chronic pain syndrome, and more.
Q: How should we report services with modifier -50 (bilateral procedure) for physician claims when a private payer’s instructions contradict our Medicare administrative contractor (MAC)?
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?
Our experts answer questions about conflicting payer and MAC guidance, identifying CPT/HCPCS services and supplies that are not separately reportable, and more.
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: 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?
Our experts answer questions about finding the right assessment tool for reporting social determinants of health, choosing CPT modifiers for same-day services, and more.
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: What advice can you give pertaining to clinical documentation requirements to properly report CPT codes for vaginal deliveries after cesarean (VBAC) procedures?
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?
Our experts answer questions about CPT reporting for use of a Jada intrauterine device after delivery, ICD-10-CM coding for other thrombophilia with atrial fibrillation, and more.
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: 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?
Our experts answer questions about 2024 ICD-10-CM guideline updates for cardiovascular conditions, documenting social determinants of health, and more.
Our experts answer questions about 2024 ICD-10-CM guideline updates for cardiovascular coding, ICD-10-PCS coding for removal of external heart assist devices, and more.
Our experts answer questions about 2024 ICD-10-CM coding for HIV-related encounters, ICD-10-PCS reporting for Impella insertions and removals, and more.
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: 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?
Our experts answer questions about documentation requirements for CPT debridement codes, sequencing social determinants of health ICD-10-CM codes, and more.
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?
