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?
