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: Can modifier -59 (distinct procedural service) be used to bypass the NCCI edit that bundles CPT codes 11055 for lesion removal and 11721 for nail debridement?
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: Would it be appropriate to use family psychotherapy CPT codes 90846-90849 to report therapy for the benefit of one person that involves input from family members?
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: A child presents to the ED with a closed fracture of his left hand. The physician performs a two-view hand x-ray that shows a small fracture. The physician reduces the fracture and performs a one-view x-ray to ensure alignment. Which CPT® codes and modifiers would be used to report the physician’s services?
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: When would it be appropriate to apply modifier -62 (two surgeons) on claims for spinal procedures performed by co-surgeons, and what effect would this have on physician reimbursement?
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: Which ICD-10-CM codes would we use to report an emergency department (ED) encounter for a patient presumed to have COVID-19 who does not undergo diagnostic testing?
Q: If laboratory results supporting a positive case of COVID-19 are included in the physician’s note for an emergency department visit, but the physician does not provide an interpretation of the laboratory results, would it be appropriate to report an ICD-10-CM code for a confirmed case of COVID-19?
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?
Q: We are seeing more fundoplication surgeries and esophageal sphincter augmentation procedures for patients with gastroesophageal reflux disease at our hospital. Do you have any tips for our coders when reporting these procedures in ICD-10-PCS?
Q: We are finding that physician documentation is lacking for vaping-related lung injuries at our hospital, making it hard to report the condition accurately. What can our coding team do to remedy this situation, and how do we accurately report vaping-related lung injuries in ICD-10-CM?
Q: A physician performed a pleural catheter flush using saline with manual clearance of clots under ultrasound guidance. Should we bill an E/M code for an outpatient office visit or report this using other CPT codes?
Q: Our coding department was told there were changes made for fiscal year (FY) 2020 when it comes to reporting healed/healing pressure ulcers and pressure-induced deep tissue damage. Can you explain any recent updates?
Q: I’ve heard conflicting information about reporting uncertain diagnoses. Do the ICD-10-CM diagnoses need to be documented in the discharge summary/final progress note or can they be coded from an earlier progress note?
Our experts answer questions about conflicts between coding guidelines and payer requirements, documentation requirements for psychiatric assessments, and more.
Q: Physicians at our hospital use the terms bacteremia and sepsis interchangeably despite each having distinct ICD-10-CM codes. How should we address this issue, and what should we do when we need to query?
Q: A patient presents for routine obstetrical (OB) care following a vaginal delivery. During the visit, the provider performs a postpartum depression screening. Should the depression screening be charged separately from the global OB visit service?
Q: When a diabetic patient has arteriosclerotic peripheral artery disease (PAD), should an additional ICD-10-CM code be assigned from subcategory I70.2- (atherosclerosis of native arteries of extremities) to describe the affected vessel and laterality?
Q: Does a psychiatrist need to document a physical examination and a review of prescriptions in order to support the reporting of CPT code 90792 (psychiatric diagnostic evaluation with medical services)?
Q: If a patient comes in twice a day over the course of a week to receive an IV infusion of Vancomycin and the same line is used daily, would the coder report one initial infusion CPT code per day?
Q: We had a patient with Type 2 diabetes who was admitted for hypoglycemia with metabolic encephalopathy. The patient also had stage 2 chronic kidney disease (CKD) and a diagnosis of hypertension (HTN). Which ICD-10-CM codes should we assign for this patient’s encounter?
Q: Our coding team saw that there is a new section for radiation therapy in the FY 2020 ICD-10-PCS Official Guidelines for Coding and Reporting . Can you explain the recent changes made to this section?
Q: The 2020 ICD-10-CM update added several new codes for legal interventions. What are these codes, and can they be assigned based on nonphysician documentation?
Q: We recently had a patient who was admitted with sepsis and the physician documented sepsis, a urinary tract infection (UTI) related to a chronic Foley catheter, and pneumonia. Can we report sepsis first instead of the complication code, or is the complication always first?
Q: Would it be appropriate to query the provider for clarification if documentation for an orbital fracture doesn’t specify the location of the fracture and whether it is open or closed?
Q: We have a diabetic patient with chronic kidney disease and hypertension who was admitted for treatment of chronic kidney disease (an Insertion of an arteriovenous graft for dialysis). Which ICD-10-CM code should be sequenced as the principal diagnosis?
Q: What would be reported as the principal diagnosis if a patient was admitted with both a urinary tract infection (UTI) and sepsis? What would be reported first if the patient developed a catheter-associated UTI with sepsis?
Q: A patient presents to a wound care clinic for assessment of a 15 sq. cm open wound. A nurse evaluates the wound and performs selective debridement. Would it be appropriate to bill an E/M code and if so, should we report modifier -25?
Q: A diabetic patient is diagnosed with a gangrenous decubitus ulcer of the left heel and admitted to the hospital for treatment. If the provider documents an association between diabetes and the decubitus ulcer, which condition should be sequenced as the principal diagnosis?
Q: Suppose a patient comes in for psychological testing evaluation. The provider interprets the test results and patient data, prepares a report, and begins treatment planning. If the interactive feedback session is held several days later, how would this be reported using CPT codes?
Q: A clinician documented "combination Type 1 and Type 2, diabetes mellitus in poor control." This condition is sometimes called Type 1.5 diabetes. What is the correct ICD-10-CM code assignment for Type 1.5 diabetes?
Q: We have a patient who received a pancreas transplant for the treatment of diabetes. The patient was later admitted to the hospital for treatment of an unrelated kidney stone. Would it be appropriate to assign the ICD-10-CM code for diabetes as a chronic condition based on the patient’s medical history?
Q: A physician orders a comprehensive metabolic panel and a quantitative blood sample to measure blood glucose level. How would a coder report these services using CPT codes, and what modifier would he or she use to indicate that the blood sample was performed separately from the panel?
Q: A patient presents to the ED seeking treatment for impacted cerumen affecting both ear canals. How would you report a bilateral cerumen removal using CPT codes?
Q: Our department has been having trouble reporting comas in ICD-10-CM. Are there any tools we can use to help us report these diagnoses more accurately?
Q: I was recently informed that providers use cellular-based tissue products to treat ulcers when a patient fails to respond to more conservative treatment options. What constitutes a failed response to treatment and how would this be documented?
Q: If our physician only documents “uncontrolled diabetes” in an admitted patient’s chart, but I can see from the lab results in the record that the patient’s blood glucose levels are high, can I assign the ICD-10-CM code for diabetes with hyperglycemia?
Q: The American Medical Association added three new CPT codes for skin biopsies, effective January 1. What are the new biopsy codes and CPT guidelines for reporting them?
Q: Which ICD-10-PCS code should be reported for an incision and drainage of a perianal abscess of the left buttocks? We are confused about which body part value should be captured since the physician documented both “perianal” and “left buttocks.”
Q: I know that the tumor, nodes, and metastasis (TNM) staging system can be used for ICD-10-CM coding purposes, but I’ve never used it before. As an inpatient coding professional, should I know how this system works and how to apply it?
Q: We had a patient with hemorrhagic cystitis. Our preprocedural plan was a cystoscopy with a bladder biopsy and cauterization. How should this be reported in ICD-10-PCS? We are having trouble choosing between Control or another root operation, and we are getting different MS-DRGs depending how the procedure is reported.
Q: A physician performs a hemiarthroplasty for a hip fracture. Would this procedure be reported with CPT code 27125 (hemiarthroplasty, hip, partial [e.g., femoral stem prosthesis, bipolar arthroplasty])?
Q: What is the difference between ICD-10-CM code I24.8 (other forms of acute ischemic heart disease) and code I21.A1 (myocardial infarction type 2)? In which situation would each of these codes be reported?
Q: Can you bill CPT codes 76981 (ultrasound, elastography; parenchyma [e.g., organ]) and 76982 (ultrasound, elastography; first target lesion) at the same time as CPT codes for liver and breast ultrasounds?
Q: I would like to add encephalopathy due to urinary tract infection to our quick coding tips, but our CDI specialists disagree on how this condition should be coded and want us to query for metabolic encephalopathy. How should this condition ultimately be reported?
