diagnosis code

  1. H

    Question Coding pressure ulcer stages, should ICD stage be updated during healing process?

    For wound care, we are asking our providers to updated their ICD-10 codes when a wound changes stages. Example Sacral pressure ulcer stage 4 at initial assessment, but as services are being rendered, after a few visits, the staging is now at a stage 3. ICD should be updated to reflect Sacral...
  2. H

    Question Surgical amputation (can it be coded as traumatic?)

    If the amputation was surgical, can we still report the traumatic amputation codes? Example, S98.11A (Complete traumatic amputation of right great toe initial encounter) since there is no code that specifies complete SURGICAL amputation of right great toe initial encounter. (Coding for wound...
  3. M

    Help with documentation

    We have a new medical provider who does not state the diagnosis or symptoms in his notes. The diagnosis codes are selected by the provider from a drop down list on another page, but not stated in the documentation portion of the note. My job is to determine the level of E/M and I'm worried about...
  4. S

    I need help with Operative report please

    I am a new coder. I'm trying to code this operative report myself before asking for a supervisor's opinion. The procedures I have concluded are 31231-50 and 32167 LT,59. H05.20 and J01.01.
  5. L

    Understanding sequencing diagnosis codes with causal relationships

    Hi, I'm not a new coder, but I have really been studying the guidelines to ensure that I have a good understanding on code sequencing. I thought it might be a good idea to get a refresher on some common scenarios I see at work. I might be overthinking this so I'm really just looking for some...
  6. H

    Suicide attempt diagnosis

    I am coding the profee side for inpatient behavioral health. I have one provider who list suicide attempt as resolved on every note but the discharge summary and of course I cannot code resolved diagnoses. Has anyone else been seeing providers mark a diagnosis as resolved on every note but the...
  7. M

    Question Code for overgrown toenails

    I'm having trouble figuring out what code to use for the diagnosis of "overgrown toenails". There doesn't seem to be a specific code for that, the closest thing I can find is L60.8, other nail disorders. Is this correct?
  8. M

    Question Osteoarthritis not specified as primary

    If the provider doesn't specify whether osteoarthritis is primary or secondary do I code for primary?
  9. P

    Wiki Appearing condition

    In radiology report of mammogram "Can we code scattered benign appearing calcifications from the findings" Impression says " NO MAMMOGRAPHIC SIGN TO SUGGEST MALIGNANCY IN EITHER BREAST. STABLE MAMMOGRAPHIC BREAST PATTERN." "Appearing" word comes which is not giving confirmation about dx present...
  10. M

    Question Which part of the documentation can Coders use to code from?

    I'm really sorry if this has been posted before but I couldn't find anything when I searched the forum (probably because I couldn't figure out how to phrase it correctly.) Which part(s) of the documentation can coders pull dx codes from? Say, the provider only listed BMI or Obesity on the...
  11. M

    Positive urine drug screen

    What is the correct diagnosis code to use when billing a urine drug screen (80305) If a patient has a positive result but the provider doesn't diagnose them with a substance abuse/dependence disorder? For example, if the patient tested positive for cocaine; should I use F14.90 Cocaine use...
  12. A

    Question Telemedicine Orginating Site Fee Diagnosis Code

    Hello! What diagnosis code is appropriate for billing the originating site fee (Q3014)? Should it be the first-listed diagnosis of the distant site claim? Thanks, Alysoun
  13. M

    Dx code for prescribing "just in case"

    Hey there, So I have a provider who, in two separate encounters, has prescribed a patient medication in case they become ill. The first was for a patient taking a hunting trip, who was prescribed an antibiotic if he were to present with respiratory issues (no previous history of, currently...
  14. A

    Coding help needed for denied modified Weil

    My physician performed a Fusion 1st MT right, Modified Weil Osteotomy 2nd MT right and Arthroplasty 2nd right. Diagnoses were Hallux Valgus, Plantar Flexed MT, and Hammertoe. I coded this surgery as 28750 (T5) / M20.11 28308 (T6, 59) / M20.5x1 28285 (T6, 59) / M20.41 I have a claim...
  15. J

    Wiki Medically indicated circumcision

    Our provider did a circumcision on a 4 mo old patient at the recommendation of the urologist after an episode of urosepsis. Z41.2 would not be an appropriate dx code in this case, but I am having difficulty figuring out what code(s) should be used. Someone suggested Z40.8 (Encounter for other...
  16. B

    Post-Term Pregnancy DX

    There seems to be a debate here in my office about the use of O48.0 for post-term. If the record indicates that the patient is 40/3, they are wanting to use that code. I am reading the definition of that code as "Pregnancy over 40 COMPLETED weeks to 42 completed weeks". Meaning the patient has...
  17. S

    Wiki Billing 64405 DX M5481 to BCBS Denied

    We bill 64405 (greater occiptal nerve block) with DX M5481 (occiptal neuralgia) to Blue Cross, they deny stating non-covered. When patient contacts BCBS, they advise patient, denial is due to the diagnosis we are billing. However, M5481 occiptial neuralgia is the reason for the occipital nerve...
  18. danskangel313

    Need help with SLE, rheumatoid arthritis, and headaches

    I'm trying to decipher an encounter note for a new patient who came in because of headaches and joint/swelling. She already had the RA diagnosis, but the provider added SLE to her problem list. Is there a way to tell which condition the joint problems are attributed to? I assumed it was the RA...
  19. Z

    Wiki Coding Falls Without Injury

    A hospital inpatient falls, but does not incur any injury or other problems as a result of this fall. What primary diagnosis code would you use? Would you use ICD-10 diagnosis code R29.6? Thank you for your suggestions!