Q: How can queries play a role in clarifying malnutrition and cachexia diagnoses while ensuring the patient’s condition is reflected in the medical record accurately for proper coding?
Q: How should a coder handle the documentation and coding of a fragility fracture when the underlying cause, such as osteoporosis, has not been clearly established?
Q: What clinical factors distinguish acute skin failure from a pressure injury, and how should the two conditions be approached from an ICD-10-CM coding perspective?
Q: When coding endoscopic procedures, some CPT codes have multiple procedures bundled in a single code. How do coders report when one of the procedures isn’t done?
Our experts answer questions on distinguishing cachexia from malnutrition for accurate coding, navigating clinical uncertainty and coding for acute skin failure and pressure injuries, and unpacking the fifth universal definition of MI.
Q: What are the key characteristics of cachexia versus ASPEN-defined malnutrition, and what ICD-10-CM codes are available for reporting each condition?
Q: What are some red flags associated with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) that might trigger payer audits?
Our experts answer questions on identifying cerebral edema and brain compression in the medical record, recognizing when documentation drives diabetes coding, and utilizing photos in queries.
Q: When reviewing neurologic cases, what documentation clues, imaging findings, and treatments should coders and CDI specialists look for to identify potential cerebral edema or brain compression diagnoses?
Q: A patient is in the office today being seen for abdominal pain six days post-op of removal of a benign tumor. After ultrasound, cholecystitis is diagnosed and the patient is scheduled for surgery the next day. Is it appropriate to use modifier -24 in this case?
Our experts answer questions on navigating sepsis coding in an era of conflicting clinical criteria, evaluating abnormal renal function in the clinical record, and addressing payer denials that passed on queries.
Q: When abnormal renal function is documented without a clear diagnosis, what clinical indicators should coders review to determine whether a provider query is warranted?
Our experts answer questions on assigning ICD-10-CM P codes versus Z codes for newborn conditions, using artificial intelligence to improve documentation and coding workflows, and coding postsurgical malabsorption.
Q: How is artificial intelligence being used in healthcare today, and what role can AI play in improving documentation and coding workflows while still requiring human oversight?
Q: How do coders determine whether to assign an ICD-10-CM P code (for maternal conditions affecting the newborn) or a Z code (for factors influencing health status) for a newborn?
Our experts answer questions on sequencing ICD-10-CM codes for unintentional poisoning with manifestations and for cases of postprocedural sepsis, as well as ensuring post-discharge query compliance.
Q: A patient with dementia has not taken prescribed Lasix for one week due to forgetting and presents with worsening acute heart failure. What is going to be sequenced first: the underdose or the acute heart failure?
Our experts answer questions on ICD-10-CM coding for adverse effects of medications, ICD-10-PCS coding for stroke intervention procedures, and coding lactic acidosis and sepsis together.
Q: What are some tips for properly documenting evaluation and management as it relates to medical decision-making, including improving communication with providers?
Q: How are stroke intervention procedures like angioplasty, transfemoral carotid artery stenting, and transcarotid arterial catheterization coded using ICD-10-PCS, and how does ICD-10-PCS handle the coding of new technology devices?
Q: A patient presents with acute respiratory failure with hypoxia due to an accidental heroin overdose. What is going to be sequenced first: the acute respiratory failure or the poisoning?
Q: What steps should medical coders take to correctly code adverse drug effects in ICD-10-CM, and when should a provider query be submitted if documentation is unclear or unspecific?
Our experts answer questions about behavioral health coding, internal coding audits, and coding non-emergency services provided in the emergency department.
Our experts answer questions on clinical recognition of pediatric malnutrition, query opportunities for unclear drug documentation, and clinical validation of tumor lysis syndrome.
Q: Why is pediatric malnutrition frequently underdocumented, and how can collaborative workflows improve documentation and coding accuracy as well as reduce queries?
Our experts answer questions about the multiple sclerosis medication administration, coding a crack cocaine overdose, and Medicare administrative contractors.
Our experts answer questions on reporting postpartum hemorrhage; combining ICD-10-CM T codes for drug-related manifestations with Z, F, Y codes; and coding hypoxic-ischemic encephalopathy.
Q: How do ICD-10-CM T codes work together with Z, F, and Y codes to fully capture drug-related conditions, and in what order should these codes be sequenced?
Q: What are the most common reasons postpartum hemorrhage is documented and coded inconsistently, and how can coders and clinicians help address these issues?
Q: A patient was initially treated for extensive burns on his lower back and the posterior side of both thighs. The physician documented that the patient had second- and third-degree burns of the lower back (2% Total Body Surface Area [TBSA] second-degree and 7% TBSA third-degree) and third-degree burns of both thighs (9%). What ICD-10-CM codes would be assigned for this encounter?
Our experts answer questions about the 2026 Medicare Physician Fee Schedule final rule, coding an excision of a ganglion cyst, and coding first-degree burns.
