Q: A patient presents with exacerbation of COPD complicated by positive COVID-19 with COVID-19 pneumonia and superimposed MRSA bacterial pneumonia in the setting of chronic bronchitis due to smoking, severe persistent asthma (not currently in exacerbation), and left lower lobe lung cancer in remission following a lobectomy one year ago. Patient continues to smoke cigarettes. How would this diagnostic note be reported in ICD-10-CM?
With guidance from Linda Martien, CPC, COC, CPMA, CPC-I, CRC, AAPC approved instructor, AAPC fellow , coding professionals can review arthritis codes to avoid the use of generalized codes in order to reflect a patient’s condition more accurately and ensure compliance with insurance requirements.
Pancytopenia is defined as the simultaneous presence of anemia, leukopenia (neutropenia), and thrombocytopenia. Refresh yourself on how each condition plays a role in diagnosing, treating, and coding pancytopenia. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, provides an overview of toxic encephalopathy including signs and symptoms, diagnosis and treatment, and relevance for coding professionals and CDI teams.
A cohort study published in the Journal of the American Medical Association found that the detection of incident stroke events is moderately accurate when using ICD-10-CM codes in Medicare claims and very accurate in ruling out non-stroke cases.
Q: Video colonoscope was advanced through a patient’s rectum to the cecum where there was normal-looking mucosa throughout. The patient had scattered diverticula in the sigmoid colon and a 6-mm sessile polyp in the proximal rectum that was removed completely by hot biopsy technique. Surgeon documented to await pathology report. How would this operative note be reported in ICD-10-CM and ICD-10-PCS?
Malnutrition affects millions of people across all age groups, and to better discuss and understand the coding nuances of malnutrition, Cokethia Rachel, CPC, CCS, CPMA, SSBBP, demonstrates how coders should define the condition, appropriately review relevant documentation, and recognize when the medical necessity of malnutrition has been supported. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS released the FY 2025 IPPS final rule on August 1, which seeks to address key social determinants of health and strengthen emergency preparedness. This rule updates Medicare payments and policies for discharges from inpatient hospitals beginning October 1, 2024.
Q: A patient is in the postpartum period after delivering a healthy baby girl. She developed diabetes mellitus during the pregnancy. She is being treated with Metformin, an oral hypoglycemic drug. How would this situation be reported in ICD-10-CM?
CMS’ fiscal year 2025 IPPS proposed rule and fact sheet proposes to upgrade certain codes describing social determinants of health (SDOH) to better capture the effect of housing instability on beneficiaries.
Q: A patient presents with a chief complaint of thoracic intrinsic spinal cord lesion causing back pain, left lower extremity sciatic-type pain, and foot drop. An MRI of the thoracic spine revealed a T11-T12 spinal cord lesion consistent with a cavernous malformation. Which ICD-10-CM codes would be reported?
Without proof that services rendered were medically necessary, third-party payers are unlikely to approve claims for reimbursement. With tips from Shelley C. Safian, PhD, RHIA, CCS-P, COC, COC-I , medical coding professionals can use ICD-10-CM codes to prove medical necessity. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: A 64-year-old female patient who has a bilateral lung transplant presents with COVID-19 (reason for admission) with acute respiratory failure. She also has immunosuppression from drugs. How would this scenario be reported in ICD-10-CM?
Verbal conversations with providers regarding reportable conditions and procedures are considered verbal queries. Refresh how they should be memorialized within the record to maintain compliance. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
A study published in the Journal of the American Medical Association found that four popular pretest risk assessment models for evaluating risk of hospital-acquired venous thromboembolism in inpatients did “not perform particularly well.”
JoAnn Baker, CCS, CPC, COC , defines sepsis and septic shock, and delves into the emerging initiative to integrate AI into the diagnosis and treatment process.
Q: A 64-year-old female inpatient has hepatocellular cancer with an orthotropic liver transplant with bile duct obstruction and is immunosuppressed due to drugs. Which ICD-10-CM codes would be reported?
Managing chronic conditions requires involvement from many parties, making documentation challenging. Assess how to improve documentation and reimbursement for chronic conditions with tips provided by Arta Kelmendi-Doko, MD, PhD . Note : To access this free article, make sure you first register here if you do not have a paid subscription.
A Journal of the American Medical Association study found that ICD-10-CM influenza codes accurately represented cases of positive diagnoses in pediatric patients, but their sensitivity was modest.
