Q: The 2026 ICD-10-CM code update, effective October 1, 2025, has new codes for flank tenderness (R10.8A-) and flank pain (R10.A-). What's the difference between pain and tenderness?
Our experts answer questions about diabetes mellitus in remission, percutaneous versus endoscopic discectomies, and complicated and uncomplicated problems.
Our experts answer questions on better coding and CDI collaboration for escalation processes and AI implementation, queries for undocumented diagnoses and cause-and-effect relationships, and codes for hemorrhages as surgical complications.
Q: When a diagnosis is clinically evident but not yet documented or there is uncertainty about a cause-and-effect relationship between related conditions, would queries be outlined similarly to other types of queries or include different information?
Q: Are there solutions for having better coding and CDI collaboration? How might this help teams with escalation processes and implementation of AI programs?
Our experts answer questions about independent historians, the number and complexity of problems addressed at an encounter, and counting discussion of management.
Q: What if a provider sends a summary of their visit with a patient to the patient’s primary care provider. Is this considered a “discussion” of patient management?
Q: What’s the difference between CPT code 90791 (Psychiatric diagnostic evaluation) and 90792 (Psychiatric diagnostic evaluation with medical services)?
Our experts answer questions on organizing clinical validation queries, the difficulty of diagnosing skin failures, and establishing an organizational definition of sepsis.
Our experts answer questions about medical decision-making, locating procedure codes, and coding a revision of a unicompartmental knee arthroplasty to a total knee arthroplasty.
Our experts answer questions on the role of prior encounters in queries, coding neoplasms in transplanted organs, and workflows for reporting malnutrition and pathology.
Our experts answer questions about the standard of care, reporting reduced services, and problems addressed during evaluation and management office visit.
Our experts answer questions on NICU coding, ICD-10-CM coding for kidney transplants with kidney failure or other complications, and the acceptance of systemwide clinical definitions on queries.
Our experts answer questions about assigning modifiers, mental health documentation and assigning evaluation and management service levels based on time.
Our experts answer questions on overcoming documentation challenges for sepsis, ICD-10-CM coding for infections of devices vs. wound infections as well as class three obesity and/or morbid obesity, and querying physician abbreviations.
Q: A month ago, a patient had undergone an open reduction and internal fixation of a traumatic fracture of the left femur. This afternoon, she was admitted for a severe and deep infection of the left thigh and immediately taken to surgery. An open, wide excisional debridement of the infected skin, subcutaneous tissue, and fascia was carried out, and the internal fixation hardware was removed. Cultures of the fixation pins grew Staphylococcus aureus. Can coders report infections of devices similar to how they would report a wound infection in ICD-10-CM?
Q: Consider a patient who received a hysterectomy two days ago and was later admitted for severe acute abdominal pain around the surgical wound. When the wound was reopened, it was discovered that an instrument had been left in her body. The instrument was removed, and the wound was resutured. How would coders report this situation with ICD-10-CM codes?
Q: Patient is a young but quite debilitated and oxygen-dependent female with a complex history and frequent hospitalizations. She currently presents with exacerbation of bronchiectasis secondary to Swyer-James unilateral emphysema, chronic postinfectious bronchiolitis obliterans syndrome following bronchiolitis obliterans in childhood, and superimposed bacterial pneumonia. Her condition is complicated by morbid obesity with a BMI of 42 and severe obesity hypoventilation syndrome with obstructive sleep apnea. How would this diagnostic note be reported in ICD-10-CM?
Q: A 64-year-old established female patient visits the orthopedic office for ankle pain and swelling. She stepped off the curb yesterday afternoon to get the mail and missed a step, her sandal caught the edge of the curb and she rolled her right ankle. Physical examination shows notable swelling in the right ankle. Full range of motion, although patient complains of discomfort on extension and flexion. Able to weight bear. X-rays negative for fracture. Based on medical decision-making rules, what would this be coded as?
Our experts answer questions on reporting bronchiectasis and pneumonia with ICD-10-CM codes, coding diagnoses without clinical criteria, and documenting pressure injuries and wound care.
Q: Consider a patient who is readmitted for postoperative pain control after a lung transplant two days prior. How would coders report this type of surgical complication in ICD-10-CM? In general, what are the guidelines for coding pain as a surgical complication of transplantations?
