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: 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: 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: 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: 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: 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?