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.
Our experts answer questions about 2024 ICD-10-CM coding for HIV-related encounters, ICD-10-PCS reporting for Impella insertions and removals, and more.
Q: Our coding department has a longstanding issue with physicians not presenting enough information to properly report CPT debridement services for ulcers, resulting in queries and denials. What do you recommend?
Q: Is there a hierarchy of social determinants of health codes? Is there an order of importance for us to sequence first, since only a certain number will fit on a Medicare claim?
Our experts answer questions about documentation requirements for CPT debridement codes, sequencing social determinants of health ICD-10-CM codes, and more.
Q: CMS recommends greater than 38°C as the upper limit temperature threshold for sepsis in the Sepsis-1 bundle, but our consulting group recommends greater than 38.3°C. What would you recommend using as the temperature threshold for diagnosing sepsis?
Q: What are some tips for organizations that are just starting out capturing the type of information to report social determinant of health (SDOH) diagnoses in ICD-10-CM?
Q: A physician performs a lithotripsy on a stone in the ureter or removes a stone from the ureter through a transurethral approach, then performs a percutaneous nephrostomy and treats a stone in the kidney. Would both procedures be reported?
