1. S

    Using an SUD specific CPT code with a BH diagnosis

    Hi there, I am trying to do some research about using 99408 which is - Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services and having a BH diagnosis for example F42.9 Obsessive-compulsive disorder, unspecified. Does...
  2. KStaten

    "Possible," "Probable," and "Likely" Diagnoses in Outpatient Setting

    Hello Everyone! It has been to my understanding that when physicians use terms like "possible," "probable," "likely," etc when referencing a diagnosis in the outpatient setting, then we cannot code for that dx and must code simply as any other applicable, associated symptom of an undetermined...
  3. R

    Question Colonoscopy w/ Snare Biopsy - missing path

    When working a procedure where the documentation supports 45385 but the resulting lab sample is lost - is the procedure still coded snare biopsy? How does this effect dx?
  4. KStaten

    Answer Suspected Diagnoses

    Hello, everyone! :giggle: I have a two-part question. 1) It is has been to my understanding that, in the outpatient setting, a suspected diagnosis cannot be coded, but instead, the symptoms thereof are to be coded until a diagnosis is confirmed. (I consider "suspected" diagnoses to be preceded...
  5. M

    Question ICD-10 codes in progress note vs codes on claim

    The software that we use allows the provider to add diagnosis codes to a section of the progress note, however a lot of the time the codes are not correct (eg. documentation says "Diabetes Type I", but provider lists code for DM type II). My supervisor insists that I need to contact the provider...
  6. D

    Dx in A&P

    Good Morning All, When we have a diagnosis that is documented in the A&P only the education team in my office is split on whether or not this is "dingable". I haven't been able to find any guidelines that says ya or nay on this topic. Any help with included resources/guidelines would help us...
  7. T

    ICD-10 Mutually Exclusive

    We are receiving quite a few denials from Ohio Anthem BC/BS due to mutually exclusive codes BUT I'm not sure they are correct. E78.00 (pure hypercholesterolemia, unsp) and E29.1 (testicular hypofunction) is just one example. It seems since October this has been happening regularly. Just...
  8. D

    ICD C77.1-is "compatible" a billable definition for a Neoplasm ?

    per CT thorax, abd and pelvis results, -Posterior Mediastinal Adenopathy, compatible with metastatic disease. This is somewhat increased from prior CT exam. I will code as C77.1, but other coder do not agree, they say compatible = uncertain, which is not billable. Please advise, thank you
  9. M

    Non-menopause related vaginal dryness ICD DIAG code?

    What is the most specific ICD 10 code for a non-menopausal women experiencing vaginal dryness? From the ICD 10 Index under atrophy/vagina (senile) I see N95.2 which takes you to the menopause/peri-menopausal section. Patient is in her early 30's. No documentation of low estrogen. Thanks for...
  10. C

    BMI diagnosis help

    Hi Everyone! Our office sees patients for preventative weight loss and nutritional counseling. We have diagnosis codes for BMIs of 25 and up since anything over 25 is considered overweight or obese. We don't have a way to bill for patients with a BMI under 25 since it is considered a normal...
  11. C

    Obesity Preventative Counseling

    We are billing G0447 to medicare in place of the standard 99202 code. Medicare is stating we need a modifier but we can't figure out which one. We have tried 33 and got denied already. We use modifier 25 for the 99212 code already. What modifier can we use to get reimbursement?
  12. N

    Diagnosis Documentation

    Hi Everyone! I'm new at the whole auditing portion, so bear with me, please! Patient is 5 months post-op odontoid screw placement, no new issues. Chief complaint says postop visit and followup for odontoid screw. The doctor doesn't state "reason for visit" or any "diagnosis". Throughout the...
  13. N

    E&M coding w/o diagnosis

    My physician documented in the assessment part of his note and billed a diagnosis of shoulder pain, however he also diagnosed osteoarthritis in his x-ray results. Since there is a definitive diagnosis, I know this should be replacing shoulder pain. If the note gets audited, will the pain dx be...
  14. L

    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...
  15. J

    Z00.00 for every follow up

    Hi, I work at a clinic and there are a couple of providers that, during a follow-up appointment, will review that vaccines, basic labs and screenings are up to date, and document it similar to this: Adult health examination - Basic labs: 11/6/17 Colonoscopy: 2/2014, 2 polyps and mild...
  16. 5

    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!
  17. M

    Renal Crisis Dx coding

    Thoughts on ICD 10 CM coding for Renal Crisis as it relates to scleroderma? Thanks for the help!
  18. J

    Sleep study diagnosis

    When the hospital receives an order from the physician with sleep apnea and in the coding process we see the report which states "abnormal polysomnogram demonstrated snoring but no significant obstructive apnea and apnea hypopnea index was only 1.1. For snoring recommend avoid sleeping in...
  19. M

    Ecode help needed

    What Ecode do I use when a patient gets dust in his eye from moving furniture? The patient sustained an abrasion to the cornea S05.02XA. I need an appropriate Ecode to place with this. Thanks Mariann
  20. C

    Diagnosis Codes Per CPT Code Within Documentation (Not 837)

    Hi all- Apologies if this is posted elsewhere. I did search around and didn't find exactly what I'm looking for. Some qualifiers before I ask my question. 1) This is for outpatient billing only. 2) I know that 5010 allows for 12 diagnoses to appear on a professional claim and there are at most 4...
  21. C

    Dg linking to plan

    Is it a requirement to have the plan show the direct link to the diagnosis code within the office note? Or is it acceptable to have a problem and diagnosis list separate from the plan documentation?
  22. L

    When and How to Code Current and Past Cancer Diagnoses

    Question: How often should cancer diagnosis be reported? Is it to be reported on ALL procedures following the active diagnosis of cancer? Example: If a patient has active cancer, but they are getting bloodwork/EKG/Urinalysis for a condition NOT RELATED to their cancer diagnosis, is cancer...
  23. M

    Help! ... Age related loss of the Y chromosome

    Does anyone know ICD-10 code for "Age related loss of the Y chromosome" ? I would appreciate any input...Thanks!
  24. Z

    Atrial Fibrillation and Cardioversion

    What ICD-10 diagnosis codes would you use to code for "atrial fibrillation status post cardioversion?" I belive I would use a complication code, but I really do not know since I am not very familiar with coding for cardiology. I would greatly appreciate any help!
  25. D

    When to use postoperative or pathology diagnosis?

    Can anyone tell me where I can find the guidelines or rules for coding a diagnosis from the postoperative diagnosis or the pathology report findings? (such as benign tumors). Through my coursework in AAPC, I have been coding from the pathology report if it gives more specific details about the...
  26. S

    Multiple same site x-rays for pre and post reduction of fractures/dislocations

    We are having a hard time deciding how to bill for these types of procedures. It is multiples of the exact same study, i.e. shoulder x-ray for a dislocation, the first study to see the problem, and the second/subsequent to make sure it is set correctly. My first question is, since these are all...
  27. H

    Help!! Need opinion

    Coding a surgery case - the doctor documents the diagnosis as aortoiliac occlusive disease. I believe the correct code to use should be I74.09, but I have another coder in my office that thinks it would be better to code is as atherosclerosis of aorta and iliac arteries. I could really use...
  28. H

    Radiology Diagnosis Coding

    Is it appropriate to use the result of a Cat Scan exam to support ordering the test? I am being asked to code from the test results when applying diagnosis codes for the encounter when the test was ordered. I feel that since they don't know the result at that point, it would be inappropriate to...
  29. L

    Medicare reimbursement for e-stem (g0283)

    I am having trouble getting Medicare to reimburse the G0283 code for E-stem performed in the Chiropractic setting. Does it only cover it with certain diagnosis codes? Any help would be greatly appreciated.
  30. K

    Breastfed baby needing Vitamin D drops

    I am a new coder and I was wondering if I can get some advice on a diagnosis coding issue. A newborn patient was recently seen by one of our providers and the doctor wanted to prescribe Vitamin D drops to prevent any Vitamin D deficiency within the baby. His reasoning is that because the baby...
  31. M

    Diagnosis Management Points Calculation - Est Problem,New Provider (same practice)

    Please let me know how many diagnosis management points you would assign???????? Scenario: An established patient to a single-specialty practice comes in for a second office visit to be seen for the same illness he was seen for 1 week ago by Dr. Smith. However, this time he is seeing Dr...
  32. J

    New Patient visit with no Dx?

    I have run in to an issue where one of my providers has a new patient appointment where all the patient wants to do is establish a relationship with the provider. This patient has nothing medical wrong with them (not on any Rx nor has any chronic issue and not currently sick). What dx code would...
  33. D

    Medial meniscus tears

    I'm billing for the radiologist for an MRI knee and the diagnosis given is medial and lateral meniscal tears. The report doesn't say anything about an injury so I don't think I can use the diagnosis codes S83.241A? Correct? The report must state injury or current injury to use these diagnosis...
  34. N


    DX: Cholecystolithiasis Biliary colic is this one diagnosis or the biliary colic is a symptom of cholecystolithiasis?
  35. C

    Abdominal US/Thoracentesis

    Good Morning All, I have a radiology department charging for an Abdominal US when they cannont complete a Thoracentesis. I am new to this group, and when I questioned an edit for an Abdominal US with diagnosis of Neoplasm of the lung and pleural effusion, I was informed that they practice...
  36. C

    0191T with cataract surgey

    Hi, I am new to coding ophthalmology surgeries. My office and I are trying to figure out how to correctly bill an I-stent with a cataract surgery on the institutional claim form. We received some CO97 denials on the claims we have billed with them so far. My questions are: Does the 0191T need a...
  37. D


    I still get confused sometimes when trying to determine level of service for an E/M. Is there a good resource book out there that helps in explaining/clarifying E&M coding? Determining the # of diagnosis, level of MDM is so confusing sometimes, it would be helpful to have a good resource that...
  38. L

    open bso, pelvic and periaortic lymph node dissection, omentectomy

    i am stumped without a malignancy diagnosis for the cpt codes for: open bso pelvic and periaortic lymph node dissection omenectomy diagnosis: atypical stromal tumor of ovary intravenous leiomyomatosis patient has history of hysterectomy for pelvic mass tia
  39. K

    Drug Screen 80300/G0477

    If your OB/GYN is screen for drugs for his pregnant patients with a "cup" screen of 10-12 different drugs. I wanted to know what diagnosis you would use if the patient has no prior use or even suspected use of drugs. Would you just code the Z36? if the "cup" shows a positive for one or more...
  40. D

    How to code Medicare Preop evaluation

    What code should I use for a Preop evaluation for a patient that is going for cataract surgery and has Medicare for insurance? I use as first diagnosis Z01.818 and was denied. Do I have to use the Z code as a second diagnosis and code the reason of the surgery first?
  41. S


    We recently added a dermatologist to our practice and he insisted that we can bill an office visit 99213 and excision for the same day with the same diagnosis code...I believe that's not right ...Please help
  42. L

    Coding Query

    Hi all....Can someone help me to understand if a patient comes with failure of a humidifier in a sleep apnea device and he had sleep apnea condition. How to code the diagnosis part in this scenario ? Do we need to code mechanical complication followed by sleep apnea condition? Thank you.
  43. C

    OP-notes - Postoperative diagnosis vs Findings (Practicode)

    I'm finally logging into my practicode subscription on a consistent basis and practicing ICD-10-CM selection. Which section of an OP note is best to use for DX selection? Findings or Post op Diagnosis? It seems like Practicode selects findings most often. How is it in the real world? In the...
  44. L

    Echo read at hospital need payable dx

    Our cardiologist reads echos (93306) done at the hospital and many times we are given a diagnosis that is not on the LCD. One question I have is if we cannot get paid for reading the echo with the given diagnosis, can the facility get paid with the same diagnosis just because they are billing...
  45. J

    Hospitalist OP ICD10-CM assignment question

    I am doing the billing (99221-99239) for our hospitalist that see our patients in the hospital and am unclear when deciding the ICD-10CM codes to use... if the patient's admitting diagnosis are different than the subsequent visit diagnosis and different than the discharge diagnosis, how do I...
  46. C

    Aspiration syndrome

    The patient is an adult and one of the diagnosis is the above. I did a query to the provider as to identify what the patient aspirated on, The provider's response was oral secretions. The patient also had pneumonia as one of the diagnosis listed. I am not sure how to code the aspiration...
  47. Y

    Medicare Mammogram Diagnosis Z12.31 or Z12.39

    I just received a notice that the diagnosis we used for a routine annual mammogram Z12.31 is not billable under Medicare. What diagnosis code should be used?
  48. K

    Rhogam Injection Diagnosis code

    What is the ICD 10 diagnosis code for Prophylatic Rhogam injection. Cross walk for V07.2 is Z41.8. I don't feel comfrotable to use this code. Thank you.
  49. K

    New to Chrio Coding

    Hi there, I am new to chiropractic coding. I understand that if it is an established patient you can not code an E/M level and a manipulation on the same day if it is the same diagnosis as before. My question is the Chiropractor I code for almost every time has an office level visit and a...
  50. H

    Billing OVs with Medicare injections for Orthopedics

    For Orthopedics, For Visco supplementation injections which occur once a week for 5 weeks with the same diagnosis code, can an OV be billed on each visit? The physician does document a physical exam, but the diagnosis code is osteoarthritis. Thanks