1. K

    Wiki Maternal Consult Prior to Preterm Birth

    A neonatologist is asked to consult with pregnant mom who is hospitalized with issues causing the expectation of premature delivery. Neonatologist counsels Mom on risks of preterm delivery to baby and what to expect for baby once she delivers (respiratory management concerns, possible NICU stay...
  2. H

    Wiki Pressure ulcer stage diagnosis

    **Posted on another thread, but trying to get as much input as possible** We are being told by our medical providers that a pressure ulcer will always be reported at it's initial severity for the duration of the wound, even if consistent care is being performed and wound is healing to a lesser...
  3. H

    Wiki 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...
  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...
  5. T

    Wiki Priority Health Unspecified DX Denials

    Is anyone else receiving denials from Priority Health when the diagnosis- even the very last dx on the claim is unspecified? I would love to connect with others who have this issue.
  6. J

    Wiki Dialysis patient admitted due to weather

    There is a patient who is going to be admitted from a nursing home who needs dialysis M-W-F. She has some medical needs, but is being admitted mainly because they want to be able to make sure she can get to dialysis due to impending weather (blizzard conditions - state issued no-travel...
  7. M

    Wiki "Consistent With" Dx

    Hello, what would you code for the diagnosis? The op report uses phrases such as "consistent with" and "likely" while the path report uses the phrase "suggestive of". I'm an outpatient coder so I'm thinking the only diagnosis I can use is R22.31. However, I thought I heard we could use a...
  8. Q

    Wiki how long after completing treatment is dx code z08 applicable?

    How long is code Z08 (Encounter for follow up examination after completion of treatment for malignant neoplasm) applicable to use post treatment?
  9. P

    Wiki Diagnosis not documented on DOS

    We are doing profee billing for hospital care services. For the initial hospital care (99221-99223) visit documentation states that patient came into the hospital and was found to have an Acute Kidney Injury secondary to Rhabdomyolysis. Coders reported N17.9 (AKI) for this encounter, not...
  10. S

    Wiki 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...
  11. KStaten

    Wiki "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...
  12. R

    Wiki 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?
  13. KStaten

    Wiki 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...
  14. M

    Wiki 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...
  15. D

    Wiki 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...
  16. T

    Wiki 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...
  17. D

    Wiki 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
  18. M

    Wiki 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...
  19. C

    Wiki 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...
  20. C

    Wiki 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?
  21. N

    Wiki 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...
  22. N

    Wiki 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...
  23. 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...
  24. J

    Wiki 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...
  25. 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!
  26. M

    Wiki Renal Crisis Dx coding

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

    Wiki 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...
  28. M

    Wiki 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
  29. C

    Wiki 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...
  30. C

    Wiki 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?
  31. L

    Wiki 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...
  32. M

    Wiki 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!
  33. Z

    Wiki 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!
  34. D

    Wiki 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...
  35. S

    Wiki 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...
  36. H

    Wiki 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...
  37. H

    Wiki 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...
  38. L

    Wiki 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.
  39. K

    Wiki 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...
  40. M

    Wiki 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...
  41. J

    Wiki 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...
  42. D

    Wiki 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...
  43. N

    Wiki Cholecystolithiasis

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

    Wiki 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...
  45. C

    Wiki 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...
  46. D

    Wiki Resource

    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...
  47. L

    Wiki 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
  48. K

    Wiki 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...
  49. D

    Wiki 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?
  50. S

    Wiki Help!

    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