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: 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: 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?
Our experts answer questions about reporting E/M codes for ED patients with chronic illnesses and choosing the right CPT code for a laparoscopic prostatectomy.
Our experts answer questions about ICD-10-PCS coding for pacemaker implants, how and when to report transcranial magnetic stimulation, and querying pathology results.
Q: Would a same date admission/discharge E/M code be used for a scenario in which a patient is admitted at 11 p.m. on a Monday, is seen by the provider at 4 a.m. on Tuesday, and discharged at 8 p.m. on Tuesday?
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 are the differences between remote therapeutic monitoring and remote physiologic monitoring and what details should we look for in documentation to report these services with CPT codes?
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: When is it permissible under Medicare to assign CPT add-on code 37186 for a secondary thrombectomy when an atherectomy is performed in the same vascular territory?
Q: What is the difference between “normal” and “abnormal” native connections in the descriptors for new 2023 CPT codes 33900-33903 describing percutaneous pulmonary artery revascularization by stent placement?
Our experts answer questions about ICD-10-PCS coding for cardiac catheterizations, reporting COVID-19 vaccination status in ICD-10-CM, and diagnosis coding for reactions to COVID-19 vaccines.
Q: For colonoscopies, is it appropriate in CPT coding to report the excision of several lesions in the same portion of colon separately if they are removed by the same technique?
Q: How do CPT codes 28295 (correction, hallux valgus, with sesamoidectomy, when performed; with proximal metatarsal osteotomy, any method) and 28298 (…; with proximal phalanx osteotomy, any method) differ?
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: New ICD-10-CM codes for unspecified vascular dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety take effect October 1. Do these new codes require linkage and specific documentation by the provider that the conditions are related?
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?
Capturing obesity as a CC 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? A: The...
Q: We are getting some National Correct Coding Initiative (NCCI) edits for repeat laboratory services. What modifier do we use if a component of a panel test is repeated later?
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: What is the best way to determine if an E/M service is above and beyond the physician work normally associated with a procedure to justify the use of modifier -25?
Our experts answer questions about CPT coding for bunionectomies, 2022 CPT changes for reporting cataract removals, and ICD-10-CM coding for false labor.
Q: What is the difference between anterior and posterior approaches to spinal surgery, and when might a physician use a combined (anterior and posterior) approach?
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?
Our experts answer questions about CPT coding catheterizations for congenital heart defects, the difference between approaches for spinal surgeries, and more.
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?
