Q: A physician documented that a pregnant patient is obese, and the patient’s chart has a listed body mass index (BMI) score. Can we assign an ICD-10-CM BMI code in this instance or should this never be done for an obstetrics patient?
Q: Considering the fiscal year 2019 update to the ICD-10-PCS Official Guidelines for Coding and Reporting for Transfer procedures, how should we now report a pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedure in ICD-10-PCS?
Q: Can an ICD-10-CM body mass index (BMI) code be used as a standalone code? If not, what documentation should we look for to justify the use of a BMI code?
Q: A lung cancer patient presents to the infusion clinic to receive chemotherapy treatments. The patient receives a Carboplatin infusion, a Gezmar infusion, and an Anzemet intravenous push. Which CPT codes would be used to report these services?
Q: What’s the difference between an incomplete miscarriage, a septic miscarriage, and a missed miscarriage and how would surgical treatments for these conditions be reported using CPT codes?
Q: We have a patient admitted with a history of chronic heart failure (CHF) and end-stage renal disease (ESRD) who was admitted with volume overload due to acute kidney injury and dialysis noncompliance. How should we report this in ICD-10-CM?
Q: We recently had a patient admitted for syncope workup. The workups were negative except for incidental findings of acute kidney injury (AKI). The physician documented “AKI likely 2/2 hypovolemia. Treatment focus is to trend creatinine levels and hydration.” Would the AKI or hypovolemia be sequenced as the principal diagnosis?
Q: I received confusing guidance regarding CPT coding for a segmental spinal fusion with pedicle screws placed at L3 and L4 vertebrae. Would it be appropriate to report CPT code 22612 with add-on code 22614 for this procedure?
Q: Our team is having a hard time determining a principal diagnosis for a patient with a history of stage 5 chronic kidney disease (CKD) who is receiving chronic hemodialysis and is in acute renal failure (ARF) with volume overload. Which ICD-10-CM code should be the principal diagnosis?
Q: If a CDI specialist doesn’t enter the queried diagnosis in his or her working DRG, but the physician responds favorably to the queried diagnosis at the time of coding (or during the retrospective query process), would you consider this in the reconciliation process? If yes, how would we capture this type of data?
Q: We have a patient who is diagnosed as having acute renal insufficiency due to dehydration with decreased urinary output and was admitted for IV hydration. What diagnosis codes should we assign?
Q: In what instance would septic shock not be coded as a principal diagnosis (PDX)? I’ve been under the impression that septic shock should always be reported as a PDX.
Q: When is it appropriate to bill CPT code 77470 (special treatment procedure [e.g. total body irradiation, hemibody radiation, per oral or endocavitary irradiation]) for a special treatment procedure?
Q: Our coding team is currently debating how to report acute tubular necrosis (ATN) in ICD-10-CM for a patient after a renal transplant. Can you provide any guidance?
Q: In ICD-10-CM, how would you report a patient who is receiving hemodialysis and has chronic kidney disease (CKD) when a failed kidney transplant is also documented?
Q: A physician performs wound debridement on a patient’s right foot, then applies bilateral, multilayer compression dressings to each leg. How should this be reported?
Q: Could you shed some light on reporting ICD-10-CM codes K66.1 (hemoperitoneum), an MCC, and R58 (hemorrhage, not elsewhere classified), which is not considered a CC or an MCC?
Q: A patient presents to the emergency department with chest pain. The physician orders multiple services along with a subsequent infusion without a stop time. What CPT codes would be used to report these services?
Q: If a patient is immobile or comatose for an extended period of time in the hospital and develops a stage 3 or 4 pressure ulcer of the left upper back, would this be considered a hospital-acquired condition (HAC)?
Q: If a patient comes into an outpatient facility for a surgical procedure and the physician evaluates the patient before performing the procedure, can you append modifier -25 to the E/M service?
Q: A patient receives treatment for two ulcers, one on his foot and one on his hip. The physician performs a subcutaneous debridement to treat the foot ulcer and a muscle debridement to treat the hip ulcer. How would this be reported?
Q: If a patient is seen for a pressure ulcer on the foot related to diabetes, would you report a diabetes diagnosis code? If surgical debridement is performed and the patient receives treatment for their diabetes, can you charge for both an office visit and debridement?
Q: We have gotten conflicting advice regarding ICD-10-CM code categories B95-B97 (Bacterial and viral infectious agents) regarding CCs, MCCs, and severity of illness/risk of mortality. Could you clarify the impact of reporting causative organisms?
Q: We are having trouble determining what qualifies a patient as having an acute myocardial infarction (MI) and what documentation would support the diagnosis. Can you help our coding team clarify?
Q: When querying a physician to confirm the stage of a pressure ulcer, is it appropriate to ask questions that require the physician to mark “yes” or “no” responses to the query?
Q: If a patient is admitted with a high blood alcohol level and the provider documents the blood alcohol level in his or her note, does the provider also need to specifically write “patient with intoxication?”
Q: According to the ICD-10-CM Official Guidelines for Coding and Reporting, uncertain diagnoses should be documented at the time of discharge. If a consultant documents an uncertain diagnosis in the final or last progress note and not in the discharge summary, can we code that uncertain diagnosis?
Q: Our facility has attempted to use the -X{EPSU} modifiers on 2017 and 2018 claims but our Fiscal Intermediary Standard System (FISS) did not process the claims. I reverted to using modifier -59 (distinct procedural service). Do you have any knowledge of when these modifiers might go into use?
Q: We keep receiving denials for our use of ICD-10-CM code G94 (other disorders of brain in diseases classified elsewhere). Is there any coding guidance out there that can help our coding team decipher when we can use this code?
Q: What should we report if you have a compression dressing that was applied to the thigh, in addition to the lower leg, since CPT code 29582 (multi-level compression bandage application, thigh to foot) was deleted for 2018?
Q: If the attending physician documented, “likely mixed cardiogenic and septic shock,” can I assign ICD-10-CM codes R57.0 (cardiogenic shock) and R65.21 (severe sepsis with septic shock)?
Q: Could you discuss or explain evaluating encounter billing vs. monthly billing for recurring outpatient services such as chemotherapy infusions or radiation oncology?
Q: I have a question regarding unilateral weakness from a previous stroke. The patient has ongoing weakness in both right arm and leg post cerebrovascular accident (CVA) and associated ataxia post CVA in 2013. What is the accurate code assignment?
Q: What would be the ideal way to code a case where a patient has ongoing encephalopathy after a subdural hematoma multiple years ago? I keep seeing documentation as a brain injury with ongoing encephalopathy, but is there a way to improve on this?
Q: Our coding department has been reviewing the AHIMA Standards of Ethical Coding but were interested in learning more about standard seven. I didn’t realize that continuing education credits help with ethical coding.
Q: Can acute respiratory failure be used as the principal diagnosis rather than ICD-10-CM code I46.9 (cardiac arrest, cause unspecified) when both are present on admission?
Q: If only a central vein is treated when performing treatment for an arteriovenous fistula, is it correct to report CPT code 36901 since 36907 is an add-on code?
Q: If you have an acute exacerbation of chronic right heart failure (CHF) with a preserved ejection fraction (EF) above 55%, can you code it as heart failure (HF) with preserved EF? All the clinical symptoms exemplify right-sided heart failure (e.g., ascites, pronounced neck vein distension, swelling of ankles and feet).
Q: Our vascular physician prescribes exercise to some of his patients who have peripheral artery disease and wants to provide the exercise program in the office because he wants to have these patients monitored closely for their response. Is there a way to get reimbursed for this?
Q: When it comes to conditions not related to hypertension, is it sufficient to attribute the diagnosis to another etiology or does the provider need to specifically document that the congestive heart failure (CHF) is not due to hypertension?
Q: Can you explain where in the clinical documentation it would be acceptable to report from for hierarchical condition category purposes? Would you code from history of present illness, past medical history, active problem list, or the assessment?
Q: If a patient is admitted for anemia related to a malignancy and is treated only for anemia, the principal diagnosis goes to the malignancy. Could you still code for the malignancy as the principal diagnosis if the patient was treated for other conditions at the same time?
Q: What are some times when it might be acceptable for a provider to copy and paste medical information into an electronic health record and when is it absolutely not acceptable?
Q: Our team had a recent case that involved a small midline episiotomy which extended to a second-degree laceration which was repaired with 3-0 vicryl rapide sutures. Would we code the episiotomy and repair or just the repair, and why?
Q: What are the applicable modifiers that can be used when a test fails for medical necessity or if an Advance Beneficiary Notice (ABN) has been signed?
Q: Is CPT code 96416 (chemotherapy administration requiring use of portable pump) the same as HCPCS code G0498 (initiation of infusion of chemotherapy in office using portable pump)? Our facility is trying to determine if it would be appropriate to set up G0498 as a Medicare override for 96416.
Q: At my institution, all of our congestive heart failure exacerbations get at least one chest x-ray. Is that enough “diagnostic testing” to code the secondary condition in accordance to Coding Clinic ?
Q: For a ureteroscopy intended as a procedure with a biopsy and double-J stent, if the procedure ends when only the scope was placed before a biopsy was taken, could you just code ureteroscopy instead of coding it with the biopsy and the modifier-74 (discontinued outpatient hospital/ambulatory surgery center procedure after administration of anesthesia)?
Q: I can't distinguish between "code first" and "in diseases classified elsewhere.” Both are used with manifestations and both can't be sequenced as principal diagnosis and both need etiology codes, so what is the difference?
Q: We use an electronic system at our hospital, and find it is difficult to query a physician since we all have our own processes. Would you recommend having a set format for a query that is used electronically?
Q: What is the best way to document time spent by physicians performing procedures? The CPT® codes state a vague time amount but the doctors struggle with this.
Q: What are the documentation requirements for a continuous infusion for an observation patient, especially spanning the midnight hour? We often see rate change or rate verification notations during continuously running infusions, but would a start and stop time be required or expected for each bag change?
Q: We are currently coding a chart for an acute kidney injury which has the baseline serum creatinine and urine output missing from the chart. Is there something we can do before we have to query the physician?
Q: When reporting multiple separate infusions of the same substance or drug provided through the same IV site during one visit, should we add up the total time and then report the appropriate codes?
