Use modifier -74 to indicate that a surgical or diagnostic procedure requiring anesthesia was terminated after the induction of anesthesia or after the procedure was started due to extenuating circumstances or those that threatened the well-being of the patient. This case study illustrates a scenario where it is appropriate to report this modifier.
Modifier -XE (Separate encounter, a service that is distinct because it occurred during a separate encounter) is used to indicate a separate surgical operative session on the same date of service or a distinct encounter after the patient has left the hospital or changed status/locations within the facility. Use this flowchart to determine when use of this modifier is appropriate.
Clinical documentation, Hospital inpatient, Training
This exercise is designed to help coders practice reading and interpreting operative reports related to the female reproductive system. As you review the operative information, your task is to assign the correct ICD-10-CM and ICD-10-PCS codes. Pay close attention to the specific terminology used in the report, including diagnoses, procedures, and any relevant anatomical references, and remember to reference coding guidelines. Once you have filled in your codes, you may scroll further down to reveal the answers.
Reading over the rules and consulting the medical decision-making (MDM) table is one way to get acquainted with the evaluation and management (E/M) office visit guidelines. But to really learn the E/M office visit guidelines, there is nothing better than seeing how they are used in real life. This code scenario will help you to do just that. In it, you’ll find a rationale so you can see the decision-making process that went into selection of each MDM element.
Sepsis coding can be challenging due to its complex presentation and evolving diagnostic criteria. These reference sheets for Sepsis-2 and Sepsis-3 provide a clear outline of criteria for coders to accurately determine when sepsis should be diagnosed and coded. Use these sheets as a quick, reliable tool to support accurate and consistent sepsis coding.
Reading over the rules and consulting the medical decision-making (MDM) table is one way to get acquainted with the evaluation and management (E/M) office visit guidelines. But to really learn the E/M office visit guidelines, there is nothing better than seeing how they are used in real life. The following code scenario will help you to do just that. In it, you’ll find a rationale so you can see the decision-making process that went into selection of each MDM element.
Coders can use these reference sheets for creating relevant and compliant queries. This resource, which serves as an invaluable tool for anyone looking to navigate the complexities of querying, was taken from the HCPro webinar “Comply with Me: A Journey to Compliant Query Practice”, presented by Natalie Negro, MPH, BSN, RN, CCDS, FACHE, the corporate CDI manager at the Hospital of the University of Pennsylvania.
Reading over the rules and consulting the medical decision-making (MDM) table is one way to get acquainted with the evaluation and management (E/M) office visit guidelines. But to really learn the E/M office visit guidelines, there is nothing better than seeing how they are used in real life. The following code scenario will help you to do just that. In it, you’ll find a rationale so you can see the decision-making process that went into selection of each MDM element.
Clinical documentation, Hospital inpatient, Training
This exercise is designed to help coders practice reading and interpreting operative reports related to lower joints. As you review the operative information, your task is to assign the correct ICD-10-CM and ICD-10-PCS codes. Pay close attention to the specific terminology used in the report, including diagnoses, procedures, and any relevant anatomical references, and remember to reference coding guidelines. Once you have filled in your codes, you may scroll further down to reveal the answers.
