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  1. R

    Secondary hypertesion

    morbid obesity with diabetes and hypertension Unless the provider documents that the diabetes or the hypertension is due to or caused by the morbid obesity, the statement of comorbid conditions, in my opinion, would not reported as secondary hypertension or secondary diabetes. According to...
  2. R

    Best code(s) for ESLD due to alcoholic cirrhosis?

    K70.40 for the liver failure due to alcoholic cirrhosis w/o coma and K70.31 for alcoholic cirrhosis with ascites
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    Diagnosis HELP!!

    Lumbar stenosis with claudicatio Per the ICD-10-CM® index entry, lumbar spinal stenosis without neurogenic claudication is reported with M48.061. Sciatica associated with intervertebral disc disorders is M51.16 for the lumbar region. Neuroforaminal stenosis (stenosis, intervertebral foramina)...
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    Wiki Guideline Hypertension, CKD, CHF and Diabetes Mellitus

    HTN, CKD, CHF and DM In the ICD-10-CM® Official Guidelines Section I.A.15, the "with" convention states that conditions that follow "with" after the main term in the index and/or have "with" in the code title are assumed to be linked unless the provider indicates that they are unrelated. There...
  5. R

    Wiki Default coding for Osteoarthritis

    osteoarthritis of wrist The correct code for osteoarthritis of the wrist is M19.03 per the index entry under the main term of osteoarthritis and sub term of wrist. The last digit will be determined by the laterality.
  6. R

    Wiki Type 2 MI/Type 2 NSTEMI/Demand ischemia

    If the documentation states type II MI, this is coded as an NSTEMI. This has been clarified by Coding Clinic for 1st Quarter 2017.
  7. R

    does this support the code?

    Do not recommend coding cellulitis based on this documentation.
  8. R

    Urosepsis due to staph aureus

    Urosepsis is not coded as sepsis. Code UTI and MSSA in diseases classified elsewhere.
  9. R

    Wiki COPD with emphysema

    Emphysema is an included term under the heading of COPD at J44 so if the documentation states COPD with emphysema then it is coded as COPD. However, if only emphysema is documented the correct code is J43.9.
  10. R

    Hypertension with Cardiovascular disease I11.9

    Hypertension with heart disease Effective 10/1/16, Coding Guidelines for ICD10 Chapter 9 state that there is an assumed link between hypertensive and heart disease/heart failure (for codes in the I50. or I51.4-I51.9) as long as the documentation does not state that the heart disease/heart...
  11. R

    ARF D/T Dehydration In A Cancer Patient that also has HTN. How to code?

    You stated that the documentation is for ARF but the code you are referencing is for CKD unspecified stage. (N18.9) There is an auto link for HTN with CKD so if both are documented and the provider does not say the CKD is NOT due to HTN, then it is coded as hypertensive CKD. However, there is...
  12. R

    COPD exacerabtion

    There is also Coding Clinic advice in 2016 that if the patient has COPD with infection and COPD with exacerbation, code both J44.0 (plus the underlying infection) and J44.1.
  13. R

    Esophageal, Gastric varices and Liver cirrhosis and Portal hypertension and Tips

    Just wanted to add that in I10, there is an instructional note at esophageal varices to code first the underlying disease so it cannot be sequenced first. There is not a note at the code for gastric varices so it can be sequenced first.
  14. R

    Using "d" as a 7th character.

    No limit if the patient is still receiving care during the healing/recovery phase.
  15. R

    DVT vs History of DVT

    This will depend on your documentation and you can look at related radiology to help paint the picture. Many times, patients are placed on anti-coagulants after a DVT or PE to prevent another from occurring. Look to make sure the PE or DVT is not documented as chronic. If not and your...
  16. R

    Confused about spinal levels/segments

    imgMap communities home adv srch contact help Back to the Basics of Spine Surgery Anatomy, Terminology Knowledge Can Improve Coding By Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA The human spine is a complex unit that combines the structures of both the nervous and...
  17. R

    HELP.... Coding Question

    You are correct, no conversion code in ICD10. Are you coding the pxs in ICD10 PCS? If so, you will code the arthroscopic portion to inspection and then code the open px too.
  18. R

    Post pancreas transplant

    You will need to code from the documentation or query the physician. If the physician documents that the patient has diabetes, then it should be coded. Medications are not the only requirement for treatment. If the patient is being monitored or having follow up exams, then the condition is...
  19. R

    Wiki ESRD w/CKD and hyperglycemia sequence help please

    If the diabetes is linked in the documentation to the CKD, then you will code both E11.22 and E11.65 as well as the CKD. This is necessary to show the complete picture of the patient's disease as E11.22 does not address the hyperglycemia. Sequencing will depend on the main reason for the...
  20. R

    VP Shunt

    S/P VP shunt is coded Z98.2 - this is listed in the index under status>shunt>VP(communicating)
  21. R

    Infusion and Chemo Diagnosis Coding

    Chemotherapy/infusion secondary dxs Section III of the Office ICD9 Guidelines for Coding and Reporting specifies which secondary diagnoses are to be included. If the diagnosis affects patient care in terms of requiring: clinical evaluation therapeutic procedures diagnostic procedures extended...
  22. R

    ICD 9 code Cancer glossotonsilalar sulcus

    Glossotonsilar sulcus cancer I agree with your code. Researching the glossotonsilar sulcus, it is the space between the palatine and lingual tonsil at the base of the palatine.
  23. R

    Preterm delivery at 23 weeks

    preterm delivery Per the Official Coding Guidelines in ICD9, an outcome of delivery code should be applied on every maternal record when a delivery has occurred. The question is whether the fetus was stillborn, or was the baby born alive and subsequently expired. Based on this, choose a code...
  24. R

    intraductal prostate carcinoma

    Intraductal prostate carcinoma ICD9 Index indicates that intraductal carcinoma should be coded to the site specified and as in situ so 233.4 would be correct.
  25. R

    Help with Coding this correctly

    some help 577.1, 303.01 (if drinks regularly/303.02 if only occasionally but then that really doesn't sound like an alcoholic), v58.69, 305.1, 401.9, 250.00 , 493.90. I would not code the fx hx as does not seem relevant and the and pain is a sx for the pancreatitis so no need to code that...
  26. R

    Vasuclar Dementia

    Vascular dementia If only vascular dementia is documented, you would code 290.4X (fill in 5th digit based on documentation) and add 437.0. If a neurological condition is documented as the cause of the dementia, then you would code that condition first. For instance, if documentation states...
  27. R

    Psychiatric diagnosis primary??

    A psychiatric diagnosis can be the principal diagnosis but make sure that your physician documents all of the related conditions as well. In the ALF setting, there are other scenarios that might come into play such as dementia with a behavioral disturbance in which case the dementia code would...
  28. R

    Implantation of port?

    For the placement of the VAD, look at CPT 36556 - 36571. These are separated by patient age as well as type of VAD (centrally inserted, peripherally inserted, tunneled, non tunneled). Also, remember to include image guidance if it is documented. Hope that helps!
  29. R

    acute hip and thigh pain s/p injection

    Does the documentation state that the pain is due to the injection? If so, then you would code post procedural pain. If not, and if no related condition is documented that causes the pain (i.e. osteoarthritis), then you would code 338.19, 719.45 and 729.5.
  30. R

    Coding for Sepsis - Just verifying

    A code from 038.XX should be PDX followed by 995.91 and the infection (0r 995.92 if there is also organ failure due to the sepsis). If the sepsis is due to candida, the coding will change and if the sepsis is underlying a complication of a procedure or device (i.e. CLABSI), then the...
  31. R

    radiology finding worded as "consistent with"

    I would code this as an abnormal finding. Consistent with is not a confirmed dx.
  32. R

    162.8 Contiguous sites

    This may be indicative of a metastatic site with an unknown primary site. Does the documentation indicate that the lung is the primary?
  33. R

    Coding Secondary Cancer

    The primary dx is dependent on which site is being treated on that visit. If both are treated equally, either may be sequenced as pcx but if the primary RCC is now history of, then the metastatic site should be the PDX.
  34. R

    Bipolar Spectrum Disorder

    If there is no specific code, I would code the bipolar, PTSD and any other dxx that are clearly stated.
  35. R

    status post CABG

  36. R

    New to Vascular, please HELP me!

    New to vascular I have always used Dr. Z's reference book for interventional radiology. (look on the web under ZHealth) You can purchase it OR it is sometimes included in the 3M encoder resource books if you have access to that. They also offer seminars around the country from time to time and...
  37. R

    Epithelial Pearl on Eyelid what code?

    epithelial pearl I would go with 374.89 - other disorders of eyelid since there is not a specific code for this diagnosis. Rhonda Talley, CCS, CPC
  38. R

    Dx for 12 month old who fell but has no injury?

    fall with no dx. V71.4 - observation following accident.
  39. R

    CKD Staging

    Ckd It is our practice to query if there is no other specific documentation in the record. Rhonda Talley, CCS, CPC
  40. R

    multiple diagnosis code help

    Codes Based on what you have listed, I would code 405.01, 44.01, 428.0, 244.9, 250.00, 530.81, 782.3, 414.01, 272.4. Rhonda Talley, CCS, CPC
  41. R

    Certification help, perhaps guidance.

    Certification Hi Martha, One of the key factors that I look at in deciding certification is financial need. Inpatient coders make more money, however, it is very difficult to get a position with no experience. Also, most require a CCS or RHIT/RHIA. Physician offices are a little more...
  42. R

    76937 once per operative session

    76937 If this meets criteria for modifier 59, you can code more than once. Since the femoral is a separate location from the jugular, even though its the same surgical session, OK to use 76937 twice. Of course, documentation must include permanent image recording, vessel patency and...
  43. R

    Help with Prinicpal Dx coding

    The principal diagnosis is the condition after study that led to the admission. From the information given, that would be the abdominal pain.
  44. R

    Renal angioplasty then stent

    Since the lesion was documented prior to this procedure and there is no documentation of a change, I would not code 36251. Also, 36251 indicated angiography from the selective location in the renal, but in this case, it was done from the abdominal aorta to confirm the lesion and the catheter...
  45. R

    Seasonal allergy

    seasonal allergy I would use 477.9
  46. R

    chief complaint/HPI

    According to our latest audit, double dipping is really an urban myth. In your example, the arm definitely describes the location so I would use it to establish the complexity in the HPI.
  47. R


    If the patient previously had abnormal findings and the new testing is to establish whether they have returned to normal, I would code the abnormal findings code as that is the reason for the encounter. One example that we encounter frequently is an abnormal mammogram with no documented...
  48. R

    Hx Pneumonia

    V12.61 is the correct code for history of pneumonia.
  49. R

    Gastroparesis in a diabetic patient

    The provider needs to establish a link between the diabetes and a manifestation of diabetes in order to code it that way. If the documentation is not clear, I would query the physician to determine if the two conditions are linked or not.