Q: How would a coder report the scenario of an unmedicated diabetic patient with diabetic renal nephrosis and out-of-control blood sugar during an encounter?
Our expert answers questions about ICD-10-CM sequencing for renal complications after a transplant, reporting malignant neoplasms in transplanted organs, and more.
Lynn Anderanin, CPC, CPB, CPMA, CPC-I, CPPM, COSC , covers FAQs she has received, specifically about CPT reporting for arthrodesis, acromioplasty, arthroplasty, arthroscopy, and spinal decompression procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Our experts answer questions about ICD-10-CM coding for diabetic patients with hyperglycemia, CPT documentation requirements for wound sizing, and more.
Q: How would the scenario of a previous kidney transplant patient presented with sepsis due to acute pyelonephritis (E. coli), CKD, and immunosuppression be reported in ICD-10-CM?
Lynn Anderanin, CPC, CPMA, CPPM, CPC-I, COSC , answers frequent questions she receives from providers pertaining to physician coding for CPT orthopedic services. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: Aside from Coding Clinic , Third Quarter 2005, pp. 19–20, is there any more up-to-date advice on reporting ICD-10-CM diagnoses from physician orders?
Our experts answer questions about CPT/HCPCS codes for reporting obesity counseling, HCPCS reporting for social determinants of health assessments, and more.
Our experts answer questions about payer criteria for chronic kidney disease diagnoses, ICD-10-CM documentation requirements for reporting chronic pain syndrome, and more.
Q: How should we report services with modifier -50 (bilateral procedure) for physician claims when a private payer’s instructions contradict our Medicare administrative contractor (MAC)?
Q: A patient who presents with complaints of progressive neck and bilateral arm symptoms is diagnosed with cervical spondylosis—worse at joints C5-C6 and C6-C7. Which ICD-10-CM codes would be reported?
Our experts answer questions about conflicting payer and MAC guidance, identifying CPT/HCPCS services and supplies that are not separately reportable, and more.
Q: Can a “yes/no” query be sent based on this documentation to confirm yes, there is a postoperative hematoma, no, there is not a postoperative hematoma, or other?
Q: What terms need to be included in physician documentation to code in ICD-10-CM whether the patient’s migraine is chronic, intractable, or with status migrainosus?
Q: A physician debrides a hyperkeratotic lesion on a patient’s left foot, second toe. During the same encounter, he performs a debridement of the five toenails. Which CPT codes and modifiers would be reported for this procedure?
Q: A patient underwent a diagnostic nasal endoscopy at 10 a.m. At 7 p.m., the patient developed an epistaxis and the physician had to use some complex cauterizing techniques to control the nosebleed. How would the physician’s services in this scenario be reported?
Our experts answer questions about finding the right assessment tool for reporting social determinants of health, choosing CPT modifiers for same-day services, and more.
Q: I’ve heard some facilities are beginning to incorporate ICD-11, even though it is not yet implemented in the U.S. How can coders help their providers transition to ICD-11?
Q: What advice can you give pertaining to clinical documentation requirements to properly report CPT codes for vaginal deliveries after cesarean (VBAC) procedures?
Q: How would a coder report a coronary artery bypass graft complicated by ineffective external cardiac device insertion, subsequent removal, and intra-aortic balloon pump placement?
Our experts answer questions about CPT reporting for use of a Jada intrauterine device after delivery, ICD-10-CM coding for other thrombophilia with atrial fibrillation, and more.
Q: One of our providers used a Jada device on a patient post-delivery, but I cannot find the corresponding CPT code. What is the CPT code for Jada device use?
Q: Are coders required to report a social determinants of health (SDOH) ICD-10-CM code when a CPT code for an E/M service level is based on medical decision-making (MDM)?
Q: A patient’s previously implanted Impella, a small, catheter-based ventricular assist device, was removed and replaced due to an emergency. How would we report this in ICD-10-PCS and which DRG would it lead to?
Our experts answer questions about 2024 ICD-10-CM guideline updates for cardiovascular conditions, documenting social determinants of health, and more.
Our experts answer questions about 2024 ICD-10-CM guideline updates for cardiovascular coding, ICD-10-PCS coding for removal of external heart assist devices, and more.
