Our experts answer questions about ICD-10-PCS coding for cardiac catheterizations, reporting COVID-19 vaccination status in ICD-10-CM, and diagnosis coding for reactions to COVID-19 vaccines.
Q: For colonoscopies, is it appropriate in CPT coding to report the excision of several lesions in the same portion of colon separately if they are removed by the same technique?
Q: How do CPT codes 28295 (correction, hallux valgus, with sesamoidectomy, when performed; with proximal metatarsal osteotomy, any method) and 28298 (…; with proximal phalanx osteotomy, any method) differ?
Q: Does documentation for a drug or alcohol use disorder need to specifically state “in remission,” or is a history of drug use sufficient to classify the condition as in remission?
Q: New ICD-10-CM codes for unspecified vascular dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety take effect October 1. Do these new codes require linkage and specific documentation by the provider that the conditions are related?
Q: Why isn't a secondary diagnosis of morbid obesity considered a complication or comorbidity (CC) by CMS? What obesity diagnoses are classified as CCs by CMS?
Capturing obesity as a CC Q: Why isn't a secondary diagnosis of morbid obesity considered a complication or comorbidity (CC) by CMS? What obesity diagnoses are classified as CCs by CMS? A: The...
Q: We are getting some National Correct Coding Initiative (NCCI) edits for repeat laboratory services. What modifier do we use if a component of a panel test is repeated later?
Q: What clinical criteria should coders use to support ICD-10-CM code assignment for upcoming 2023 dementia codes in category F02 (dementia in other diseases classified elsewhere)?
Q: What is the best way to determine if an E/M service is above and beyond the physician work normally associated with a procedure to justify the use of modifier -25?
Our experts answer questions about CPT coding for bunionectomies, 2022 CPT changes for reporting cataract removals, and ICD-10-CM coding for false labor.
Q: What is the difference between anterior and posterior approaches to spinal surgery, and when might a physician use a combined (anterior and posterior) approach?
Q: Our coding team has been having trouble understanding how to correctly report diabetes mellitus (DM) “with” other conditions in ICD-10-CM. Can you provide some guidance on this issue?
Q: I’ve been told that if there are clinical indicators to support that chronic kidney disease (CKD) is the etiology of a patient’s hypertension, an ICD-10-CM code from category I15.- (secondary hypertension) would be assigned. Since codes from category I12.- (hypertensive chronic kidney disease) also capture CKD with hypertension, what is the best code category to be reporting from?
Our experts answer questions about CPT coding catheterizations for congenital heart defects, the difference between approaches for spinal surgeries, and more.
Q: If a physician documents a patient as HIV positive, should the ICD-10-CM code Z21 be reported? What about if they document the patient is HIV positive with an HIV-related illness—would that be reported with ICD-10-CM code B20?
Q: We recently had a patient with a history of diabetes admitted with gangrene of the left second toe. Can you review any guidance related to ICD-10-CM coding and documentation for a case like this?
Q: We recently had a patient admitted after a vertebral body tether procedure for scoliosis. Were there any changes to the fiscal year 2022 ICD-10-PCS codes for procedures related to this?
Q: Effective January 1, CPT codes 94625 and 94626 will replace HCPCS code G0424 for pulmonary rehabilitation. Will these new CPT codes have the same reporting requirements as G0424?
ICD-10-CM codes for traumatic fractures specify the type of bone injury, affected area of the body, and in some cases, the degree of soft tissue damage. Review orthopedic terminology and documentation requirements for traumatic fractures to resolve the coding challenges.
Q: Our facility has been seeing more denials lately for acute respiratory distress syndrome (ARDS), especially when both respiratory failure and ARDS are documented in the same record. How should ARDS be reported in ICD-10-CM, and which MS-DRG does this diagnosis group to?
Q: What are the reporting requirements for CPT code 99483 (assessment of and care planning for a patient with cognitive impairment) for cognitive assessment and care planning services?
Q: A wound care patient with a 25-sq-cm chronic foot ulcer presents with a new cellulitic rash, which is treated using topical medication. During the visit, the physician also surgically removes dead tissue from the ulcer. How would these services be reported in CPT?
Q: Our coding team has been having trouble reporting post-operative complications due to vague physician documentation. What language might you suggest that physicians use to clarify that the complication is indeed due to surgery?
Q: The 2022 ICD-10-CM code set includes a new code, U09.9 (post-COVID-19 condition, unspecified), for post-COVID-19 conditions. When would it be appropriate to report this code? A: The fiscal year...
Q: We have a patient admitted for heart failure who is also being treated for latent autoimmune diabetes of adulthood (LADA). What is LADA and how would it be reported in ICD-10-CM?
Q: A 32-year-old female presents for a planned vaginal delivery of twins. Twin A is delivered vaginally but due to complications, the second-born is delivered via a caesarean section (C-section). How would these obstetric services be reported in CPT?
Q: We recently had a patient admitted with severe acute meningitis causing respiratory decompensation. A diagnostic lumbar puncture and mechanical ventilation were both performed during the inpatient stay. Which of these two procedures would be the principal procedure?
Q: Would telemetry and the continuation of home medications be considered continued care for a myocardial infarction (MI) or treatment when reporting in ICD-10-CM? Would this meet the definition of a secondary diagnosis?
Q: Per Coding Clinic, Second Quarter 2017, when a spinal fusion is performed without bone grafting it cannot be coded to the root operation Fusion in ICD-10-PCS. Is this advice still accurate?
Q: When might it be appropriate to report CPT codes for multiday electroencephalograms (EEG)? In addition, should these codes be billed on the day of initiating or ending the EEG study?