diagnosis coding

  1. starrlaw

    Wiki DX codes for hospital follow up with PCP

    Good afternoon all! I am trying to find any information regarding the use of DX codes from hospital, UC, or ED documentation when the PCP is seeing the patient for first encounter after discharge. We have had some discussion in our office regarding what DX should be used on this visit. Should...
  2. D

    Wiki Settle a debate for me...

    The guideline for Z51.11- Encounter for antineoplastic chemotherapy and Z51.12- Encounter for antineoplastic immunotherapy is being argued as to what way it should be applied. One side is saying that these codes should be applied to claims for patients who are being treated for a cancer with a...
    • dbrewbaker
    • Thread
    • antineoplastic chemotherapy coding diagnosis coding encounter immunotherapy
    • Replies: 2
    • Forum: ICD-10
  3. N

    Wiki Diagnosis discussed

    I have a provider suddenly saying he discussed the diagnosis above but doesn't list what he discussed. Normally I would remove them but then he put the time spent with the patient. Do I leave the Dx with no treatment plan or leave them? 99214 M25.811 S90.221A S90.222A I25.810 D69.3 I73.9...
    • ny2scgirl
    • Thread
    • diagnosis coding evaluation and management
    • Replies: 0
    • Forum: ICD-10
  4. H

    Wiki 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...
    • hildapgarciav
    • Thread
    • diagnosis diagnosis code diagnosis coding diagnosis documentation diagnosis needed guideline help guidelines
    • Replies: 1
    • Forum: ICD-10
  5. S

    Wiki Pulling from Problem List

    I know a diagnosis code can be used if problem is documented on or before the date of service, but how far are we able to go back into the patient's chart for this information?
  6. K

    Wiki Sample cases for practice

    Hi, I found one website for Inpatient sample charts. You can subscribe or become a follower to get updates of the website. There is lot of DRG coding sample charts and sample questions in this website. www.inpatientmedicalcoding.com
  7. B

    Wiki Dx Coding and ROS

    Can a diagnosis code be pulled solely from the review of systems alone? I was recently dinged on an audit for a dx code the auditor believes I should have added. The code in question is R39.11 for urinary hesitancy, only mention of urinary hesitancy within the note was in the ROS. It is my...
  8. L

    Wiki diverticulitis perforation vs crohn's disease

    i have a hospital follow up patient that has the chief complaint of "perforation and abscess of large intestine concurrent with and due to diverticulitis". The imaging shows a left colon perforation. the patient also has "medically difficult to manage IBD". it was difficult for the physician to...
  9. L

    Wiki Diagnosis coding at Surgical Facility

    Can anyone point me to guidelines for diagnosis coding at surgical facility? I am interested specifically which should be included besides the pre-op and post-op diagnosis. Where can co-morbidity be pulled from reasonably? Only the H&P or should additional provider notes within the previous...
  10. C

    Wiki E662 vs E6601

    HI! Currently our practice uses E662 for morbid obesity dx recently we've looked into E6601 but are unsure if it would be a covered dx since the description is "morbid obese due to excess calories". To me, I can't imagine an insurance seeing that as a medical condition whereas E662 is morbid...
  11. K

    Wiki car accident billing

    I had a patient come in to our urgent care today who wanted to be seen for injuries sustained in a car accident. She said she didn't intend to open a claim with her auto insurance and wanted us to bill her medical policy. I explained that we only accept cash payment for car accidents because...
  12. L

    Wiki Diagnosis order

    I am having a hard time trying to understand the pecking order for diagnosis codes that have -use additional code to identify under a chapter then also -use additional code to identify underneath the code you are choosing. For example: Hypertensive diseases (I10-I16) -it says to use additional...
    • lymanj1
    • Thread
    • diagnosis diagnosis coding guideline help please icd-10 rules
    • Replies: 0
    • Forum: ICD-10
  13. B

    Wiki Coding from HPI for LTC

    Hello All, I work in LTC and I got a notification from one of my MDS nurses that they had added a dx of Dementia for a resident, but I did not have it on my diagnosis sheet for that particular resident. I went through all the documentation and could not find a dx or dx code of Dementia for said...
  14. 5

    Wiki Diagnosis codes alphabetical order

    Hello, we just received a denial from blue cross that said: We are unable to process the claim: 203 diagnosis codes must be entered in alphabetical order a-l 019 invalid diagnosis code pointer has anyone else had this type of an issue? Thank you!
  15. M

    Wiki Dx Coding for Hydrocephalus Patients

    After reviewing below scenario, how would you code and sequence the diagnoses? - Would you code the symptoms first and then the hydrocephalus (headache-R51, nausea-R11.0, hydrocephalus-Q03.9)? Or instead of coding the hydrocephalus, code the presence of the CSF shunt (R51, R11.0, Z98.2)...
    • maryv22
    • Thread
    • diagnosis coding headaches hydrocephalus sequencing shunt
    • Replies: 3
    • Forum: Diagnosis Coding
  16. M

    Wiki 86592 Chlamydia

    A patient was seen at our family care office. He had been told by the health dept that he may need to be treated a second time for chlamydia. Our dr ordered 86592. Test results were negative. Am I able to code z11.3 since we are looking for the infection again? If not, what can I use? I...
  17. J

    Wiki Uncontrolled Diabetes in ICD10-Coding Clinic

    Hello All. Having this discussion with a coding vendor and there is some confusion. When ICD-10 came out a big change was that Uncontrolled Diabetes was coded as E1165 Diabetes with hyperglycemia rather than E119. This Coding Clinic determination was pointed out to me and I'm having a hard time...
  18. danskangel313

    Wiki Coding Diagnosis Based on Procedure? Concussion vs Unspecified Intracranial Injury DX

    I'm coding a scenario in which the patient had a craniectomy due to a brain injury and the provider documented specifically that the patient had a diagnosis of "Concussion" (with loss of consciousness, 16 hrs). I'm being advised that I should be coding S06.9X4 for unspecified intracranial injury...
  19. danskangel313

    Wiki Coding Diagnosis Based on Procedure? Concussion vs Unspecified Intracranial Injury

    I'm coding a scenario in which the patient had a craniectomy due to a brain injury and the provider documented specifically that the patient had a diagnosis of "Concussion" (with loss of consciousness, 16 hrs). I'm being advised that I should be coding S06.9X4 for unspecified intracranial injury...
  20. T

    Wiki Physician needs proof

    One of the physicains I code for does not think she needs to add the diagnosis to the assessment portion of the EMR. She likes to use the special history and put everything in there. She feels that to put the diagnosis in the assessment is doing double documentation and she does not like to do...
  21. K

    Wiki Coding w/o a pathology

    Patient referred to our oncologist with a solitary pulmonary nodule, no pathology. The physician has entered a cancer diagnosis into the patient's EMR. She states that this is a clinical diagnosis based on her findings and patient history. I have advised her against this in the event that...
    • KMayercsik
    • Thread
    • diagnosis diagnosis coding medical records request pathology patient
    • Replies: 6
    • Forum: Diagnosis Coding
  22. M

    Wiki Oral Lesion??

    Doctor gave the dx of "oral lesion" do I need more information to code correctly or is there a code for this?? I was thinking 528.00 but it does not specifically say lesion. :confused:
  23. D

    Wiki Potential Ethical Issue Medicare Risk Adjustment

    :confused:I am a Medicare Risk Adjustment Coder. We review medical records for diagnosis codes. Presently, I am performing quality assurance reviews on my co-workers code choices. If I reject their choices, the records go to my supervisor for a 3rd review. When this process is completed, the...
  24. M

    Wiki MVA resulting in the loss of twins at 8mo gestational age

    We are trying to figure out the diagnosis coding for the orthopedic surgeons who were called in to do fracture repair in this scenario: A patient who was 8 months pregnant w/twins was in involved in a severe head-on MVA resulting in multiple fractures and injuries including uterine rupture and...
    • Margaret Roddy
    • Thread
    • diagnosis coding obstetrics orthopedic surgery
    • Replies: 0
    • Forum: OB/GYN
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