Q: If our physician only documents “uncontrolled diabetes” in an admitted patient’s chart, but I can see from the lab results in the record that the patient’s blood glucose levels are high, can I assign the ICD-10-CM code for diabetes with hyperglycemia?
Q: The American Medical Association added three new CPT codes for skin biopsies, effective January 1. What are the new biopsy codes and CPT guidelines for reporting them?
Q: Which ICD-10-PCS code should be reported for an incision and drainage of a perianal abscess of the left buttocks? We are confused about which body part value should be captured since the physician documented both “perianal” and “left buttocks.”
Q: I know that the tumor, nodes, and metastasis (TNM) staging system can be used for ICD-10-CM coding purposes, but I’ve never used it before. As an inpatient coding professional, should I know how this system works and how to apply it?
Q: We had a patient with hemorrhagic cystitis. Our preprocedural plan was a cystoscopy with a bladder biopsy and cauterization. How should this be reported in ICD-10-PCS? We are having trouble choosing between Control or another root operation, and we are getting different MS-DRGs depending how the procedure is reported.
Q: A physician performs a hemiarthroplasty for a hip fracture. Would this procedure be reported with CPT code 27125 (hemiarthroplasty, hip, partial [e.g., femoral stem prosthesis, bipolar arthroplasty])?
Q: What is the difference between ICD-10-CM code I24.8 (other forms of acute ischemic heart disease) and code I21.A1 (myocardial infarction type 2)? In which situation would each of these codes be reported?
Q: Can you bill CPT codes 76981 (ultrasound, elastography; parenchyma [e.g., organ]) and 76982 (ultrasound, elastography; first target lesion) at the same time as CPT codes for liver and breast ultrasounds?
Q: I would like to add encephalopathy due to urinary tract infection to our quick coding tips, but our CDI specialists disagree on how this condition should be coded and want us to query for metabolic encephalopathy. How should this condition ultimately be reported?
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?
