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    Post tonsillectomy hemorrhage

    I am having difficulty finding the appropriate ICD-10 code for post tonsillectomy hemorrhage. Thank you!
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    It appears that without any further qualifiers, I am unable to code PMH of "lupus." I do ER coding, and I am finding "lupus" quite frequently in the PMH, but without a qualifier, I'm not sure how to code it. This is what my encoder says: * Anticoagulant * Discoid (local) * Erythematosus...
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    G6PD deficiency?

    I found this thread with ICD-9 codes: When coding out G6PD deficiency starting with "deficiency" and then glucose-6-phosphatase, it takes me to either glucose-6-phosphatase deficiency (von Gierke disease) or glucose-6-phosphate...
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    Weeks of gestation with spontaneous miscarriage?

    Is it required to code weeks of gestation when there is a documented spontaneous miscarriage? If not known, code unknown weeks?? Thank you!
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    Weeks of gestation

    I'm hoping someone might be able to shed some light. I've spent quite a bit of time researching this, and it is so early in the ICD-10 process, I really am not finding anything. I've been instructed by a lead coder to NOT code the weeks of gestation if it is stated as "estimated,"...
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    Postpartum condition versus complication?

    Coding guidelines state that ANY condition being treated during pregnancy is to be defaulted to a pregnancy complication, i.e., It is the provider's responsibility to state that the condition being treated is not affecting the pregnancy. As regards postpartum conditions, the guidelines state...
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    Periprosthetic fracture AND prosthesis dislocation

    My diagnosis is posterior hip dislocation with periprosthetic greater trochanter fracture. I have a code for a periprosthetic fracture of the hip, right, initial, (T84.020A) and a code for prosthesis dislocation of the hip, right, initial (T84.040A). Do I use both, or is there a better code...
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    Wiki "Infected laceration repair"

    Patient presents to ED with knee pain and swelling, S/P laceration repair 3 days ago. Clinical Impression is "infected laceration repair, right knee." From what I'm reading (granted, it is an ICD-9 Coding Clinic), the coder "should assume that the wound is the problem and the source of the...
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    Detailed (?) extremity exam with 1995 guidelines

    There isn't a lot of information out there about this, at least that I can find. Here is my exam, and I'm trying to figure out if this justifies a "detailed" extremity exam. VS: (documented but not reiterated here). GENERAL: (documented but not reiterated here). RESP: (documented but not...
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    Detailed (?) extremity exam with 1995 guidelines

    There isn't a lot of information out there about this, at least that I can find. Here is my exam, and I'm trying to figure out if this justifies a "detailed" extremity exam. VS: (documented but not reiterated here). GENERAL: (documented but not reiterated here). RESP: (documented but not...
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    Path report: Basaloid neoplasm

    I am coding for facility only so only have the path available. Diagnosis according to the path report is "basaloid neoplasm." I have no idea as to an ICD-9 code here. Pre-path diagnosis is 238.2, neoplasm of uncertain behavior. Do I have to default to this code as post, also? Thank you!
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    Dual coding - Current TIA with CVA residuals

    We are dual coding ER charts right now, and my patient has a current TIA with residuals from a prior CVA of generalized weakness and dysarthria. I attempted to code these conditions through my Encoder and then through my Coding Book but got an Excludes1 note that I can't use these codes...
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    Disk bulge and facet hypertrophy

    I have an MRI with report stating: L5-S1: Mild posterior bulge is present without canal narrowing. Mild foraminal narrowing is noted on the right related to bulge and facet degenerative change present. On the left, similar mild narrowing is noted related to mild bulge and facet hypetrophic...
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    ROS "all systems negative except as marked"

    On the E&M worksheet, we can count a complete ROS *if* there is at least one system reviewed plus the statement "all systems negative except as marked".....and we know we can pull ROS elements from the HPI if not already accounted for. However, if the only ROS element I have is in the HPI *and*...
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    History of MRSA and MRSA carrier?

    Can someone explain to me the difference between "history of MRSA" (V12.04) and "carrier or suspected carrier of MRSA" (V02.54). Thank you!
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    Wiki Dementia and Parkinson disease - ICD-10 Code for Parkinsons disease

    My patient has "dementia" and "Parkinson disease" with no cause-and-effect relationship implicitly stated by MD. In coding these, my Encoder takes me to an option on Parkinson disease of: 1) With dementia 2) Parkinson disease alone Because the guidelines state that "with" actually means "due...
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    Components of extremity PE

    I have a physician who will document vital signs (constitutional) and then an extremity exam but absolutely nothing else, as follows: There is a puncture wound in the plantar heel, surrounding soft tissue swelling, but no erythema, drainage, or purulence. Ankle is normal to inspection...
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    Oncocytic cyst

    I am stumped on this one. All I have is a path report, no access to the operative report. Preprocedure diagnosis from performing MD is "gingivolabial sulcus neoplasm," and the path came back with "oncocytic cyst with abscess, negative for carcinoma." I am not finding anything on the oncocytic...
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    Additional references for coding acute on chronic pain

    I am looking for additional references on coding acute on chronic pain. I have read everything I can possibly find, Advance articles, many threads here, but I am just not grasping it. Just when I think that I have it down, I have another coder in my department look at my codes, and they are...
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    CC: Family requests workup of multiple falls

    I'm really struggling with the coding of this case. Family requests workup of the cause of patient's recent frequent falls. Patient also has multiple abrasions as a result of the recent falls. I really can't give you much more info other than the above because there really ISN'T much more than...
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    OB ultrasound - V28.81 versus V28.3 (see HBM April 2015)

    In the new Healthcare Business Monthly, there is an article on OB ultrasounds 76805 and 76811. I am a little confused regarding the diagnosis codes V28.3 and V28.81. We have been utilizing V28.81 when patients present for an antenatal ultrasound for dates and anatomy. Our physicians order...
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    Use of social history in E/M determination

    Are you able to count "social history" as an element of your HPI determination if there is a discrepancy in that information? Example: It is documented in one location as "ex-smoker" (or "former smoker" or similar) but in another location as "smokes cigarettes daily." I'm thinking you cannot...
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    ISO: Medical Necessity resources

    I'm not sure where this would go, so I'm defaulting to this forum. I'm looking for resources on Medical Necessity as it pertains to E/M in particular. I'm looking for web sites, forums, webinars, etc., pretty much anything. I've tried a search in the webinar archives here at AAPC and crashed...
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    Remote companies and internet access

    I have a job offer from a company that is contigent on me finding a different internet provider. We live on a mountain and have ONE choice for internet and that is satellite which is the one form of internet that can't be used with this particular company. Do any of you know if any remote...
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    "Dropping off specimen" for culture

    Our office has the capability to run a UA, but we do not have the facilities to run a culture. Therefore, it has to go to an outside lab for culture. Some of our chronic UTI patients will come to the office for the sole purpose of leaving a specimen for culture. We collect it for them, i.e...
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    NCCI Edit versus AUA Bulletin

    I have conflicting info here. I have a Coding Brief from the American Urological Association, stating that CPT 52353 (cysto with ureteroscopy and/or pyeloscopy with litho) and 52332 (cysto with stent placement) have been combined to one CPT code of 52356 (cysto with ureteroscopy and/or...
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    Bladder CA 188.9 versus hx of bladder CA V10.51

    I have a question regarding the use of 188.9 versus V10.51. We see bladder CA patients routinely for surveillance cystoscopy, sometimes every 3 months for several years and then yearly, etc. ICD-9 says that once the previous malignancy has been excised and there is no evidence of existing...
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    Aspiration in global of hydrocelectomy

    Can I bill for aspiration in the global period of a hydrocelectomy? Using a Toshiba unit, scrotum was scanned. Left testicle unremarkable, but there is a moderate-sized fluid collection inferior to the testicle. A spot on the scrotum was anesthetized, and 10 mL of fluid was aspirated without...
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    Determining level of HPI

    I understand about the 8 criteria (location, quality, severity, etc.) and how to apply it when the patient comes in with a new problem, i.e., The patient comes in complaining of RIGHT ARM pain that has been going on for A WEEK and is EXACERBATED BY any twisting motion and MADE BETTER by Tylenol...
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    Looking at Anaheim...

    I'd really like to try to make it to Anaheim. I didn't see any information on line for hotels close to the Disneyland Hotel (venue for event). Does anyone know of any hotels that would be within walking distance?
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    Diverticulosis = high risk colonoscopy?

    I cannot for the life of me find this in my documentation or on the web. A patient had his first screening colonoscopy for Medicare, but he has a history of diverticulosis. Does this constitute G0121 or G0105? Thank you!
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    Consultation re major change in bowel habits

    Patient presented solely for major change in bowel habits and episode of rectal bleeding. However, in discussing history, physician noticed that the patient had polyp removal with POSITIVE cancer in the polyp 3 years ago, and the patient is due right now for 3-year cancer followup. Diagnosis...
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    Central lines

    These will be the death of me. I know there are several factors that come into play with these things: Central or peripheral? Tunneled or nontunneled? Patient age? With or without port or pump? I can differentiate the central or peripheral and obviously the patient age. I'm not...
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    Wiki Those pesky 99241-99245 and 99251-99255 codes that are not recognized

    I was taught in a Boot Camp last year that Medicare (and consequently more companies) are no longer recognizing 99241-99245 and 99251-99255 codes (outpatient and inpatient consultations). First of all, I don't fully understand why those codes are still in existence if more and more companies...
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    Diagnoses for colonoscopy :/

    PREOP/POSTOP DIAGNOSES: Hematochezia, obstipation, chronic. INDICATIONS/FINDINGS: The patient is a 26-year-old woman with a hx of chronic obstipation, irregular bowel movements with passage of bright red blood. She also has concerns because there is a family hx of colon cancer in 2 family...
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    New code 52356

    CCI for 52356: Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent. We have some confusion as to the codes incorporated by this new code. ...A 20-French scope was inserted, and urethra, prostate, and bladder were...
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    ICD - Family history pancreatic CA?

    This patient has a very strong family history of pancreatic CA, and I'm looking at an ICD-9 code for this. As near as I can tell, *technically* family history of pancreatic CA should be V16.0. However, this code is on a colonoscopy. This is the reason this patient is having her colonoscopy...
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    Scrotal trauma?

    Struggling with whether I can code the scrotal exploration or just the wound repair.... "Exam under anesthesia revealed that this was not a deeply penetrating injury. Using a Pean we probed and found there was an obvious tract from left anterior to right lower lateral. We left the Pean in for...
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    52320 + 52353

    I'm wondering why CCI Edits say 52320 and 52353 can be billed together, but everything I've read on this site says they can't. This is a combo my doc uses frequently (and codes himself), so any help is appreciated. Can anyone explain a little more? Thanks!
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    HIPAA violation?

    I'm not even sure how to sure this on the internet, so I'm turning to you all here. I work at an office where there is a glass window separating reception from the office (though the glass window is never closed, but that is another story). There are 2 people who work in the "office" part of...
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    I am so confused :confused: He calls this, "Bilateral mastectomy with right sentinel axillary node biopsy." The patient was again identified and the site and procedure confirmed. The patient was then given general anesthetic. Operative sites were prepped and draped with sterile towels. Both...
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    Transrectal ultrasound....

    The prior coder for this office left me these notes with these codes for this procedure: Rectal exam was done, and prostate was unchanged from prior exam. Using the Toshiba unit and a 6.0 Hz probe, the prostate was scanned in transverse and longitudinal planes. Hard copies were taken of the...
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    (duplicate post to GE) Open excision of anorectal tumor at time of colonoscopy

    (This is a duplicate post to the post on GE board) I'm not sure about the coding of this anorectal mass (tumor) that was done at time of colonoscopy. The Olympus video colonoscope is introduced and advanced through a tortuous sigmoid, identifying diverticula. The instrument was then advanced...
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    Open excision of anorectal tumor at time of colonoscopy

    I'm not sure about the coding of this anorectal mass (tumor) that was done at time of colonoscopy. The Olympus video colonoscope is introduced and advanced through a tortuous sigmoid, identifying diverticula. The instrument was then advanced to the cecum. The instrument was then withdrawn...
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    Yet another question about screening colonoscopy

    We are experiencing so many issues with screen versus diagnostic versus surveillance colonoscopies. I understand that every single situation is different, but here is the current one. Patient was scheduled for colonoscopy (yes, scheduled by another physician with our office) for "abnormal...
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    Reporting initial consult with surgeon when it results in scheduling surgery

    (I am posting this after reading "Report Presurgical H&P With Caution" in January 29, 2013, AAPC News.) After reading the above article, I have a question similar to Dawna's. I'm not seeing where her question was clearly answered. The above article addressed billing out initial consults when...
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    Liver biopsy (NOT percutaneous) @ time of lap chole

    Skin incision is made in the midline just below the umbilicus, carried down through the peritoneum. A pursestring was placed around the fascial opening to be tied later. The disposable cannula was then placed in this wound. The abdomen was insufflated. The remaining 3 cannulae were placed. The...
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    Stent removed LT and stent placed RT

    This gentleman had: Cystoscopy. LEFT stent removal. RIGHT ureteropyeloscopy. RIGHT laser lithotripsy. RIGHT stone basketing. RIGHT stent placement. Insurance is denying because stent removal bundles. However, because it is on the opposite side, wouldn't that be reimbursable? I don't see why...
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    Bladder ultrasound - 76775 vs 51798

    Our nurse will typically perform this before a patient's office visit, and this would be the most likely dictation (in addition to remainder of OV): BLADDER ULTRASOUND: Using a Toshiba Nemio XG unit and a 3.75 MHz probe, the bladder was scanned in transverse and longitudinal planes. Postvoid...
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    One more question...

    From what I can gather from the internet and my understanding of the procedures.... ESWL and laser lithotripsy are two very different things and: ESWL - 50590 Laser - 52353 Is this correct? Thank you for all your help!