Q: A patient who presents with complaints of progressive neck and bilateral arm symptoms is diagnosed with cervical spondylosis—worse at joints C5-C6 and C6-C7. Which ICD-10-CM codes would be reported?
Q: Can a “yes/no” query be sent based on this documentation to confirm yes, there is a postoperative hematoma, no, there is not a postoperative hematoma, or other?
Q: I’ve heard some facilities are beginning to incorporate ICD-11, even though it is not yet implemented in the U.S. How can coders help their providers transition to ICD-11?
Q: How would a coder report a coronary artery bypass graft complicated by ineffective external cardiac device insertion, subsequent removal, and intra-aortic balloon pump placement?
Q: A patient’s previously implanted Impella, a small, catheter-based ventricular assist device, was removed and replaced due to an emergency. How would we report this in ICD-10-PCS and which DRG would it lead to?
Q: Is there a hierarchy of social determinants of health codes? Is there an order of importance for us to sequence first, since only a certain number will fit on a Medicare claim?
Q: CMS recommends greater than 38°C as the upper limit temperature threshold for sepsis in the Sepsis-1 bundle, but our consulting group recommends greater than 38.3°C. What would you recommend using as the temperature threshold for diagnosing sepsis?
Q: A patient with fatty liver disease undergoes ultrasound cavitation. What diagnoses are treated using ultrasound cavitation and how is the procedure reported in ICD-10-PCS?
Q: A 4-year-old managing lissencephaly, hypotonia, and dysphagia with aspiration of secretions presents with fever and tachypnea. A chest x-ray shows right lower lobe infiltrates. Would it be appropriate to query the provider to confirm a diagnosis of pneumonia?
Q: What ICD-10-PCS codes would be used to report Stage 1 of a metatarsal resection involving Excision of nonviable tissue for diagnostic purposes and partial detachment of the fifth metatarsal?
Q: Does documentation for a drug or alcohol use disorder need to specifically state “in remission,” or is a history of drug use sufficient to classify the condition as in remission?
Q: Why isn't a secondary diagnosis of morbid obesity considered a complication or comorbidity (CC) by CMS? What obesity diagnoses are classified as CCs by CMS?
Q: What clinical criteria should coders use to support ICD-10-CM code assignment for upcoming 2023 dementia codes in category F02 (dementia in other diseases classified elsewhere)?
Q: Our coding team has been having trouble understanding how to correctly report diabetes mellitus (DM) “with” other conditions in ICD-10-CM. Can you provide some guidance on this issue?
Q: I’ve been told that if there are clinical indicators to support that chronic kidney disease (CKD) is the etiology of a patient’s hypertension, an ICD-10-CM code from category I15.- (secondary hypertension) would be assigned. Since codes from category I12.- (hypertensive chronic kidney disease) also capture CKD with hypertension, what is the best code category to be reporting from?
Q: If a physician documents a patient as HIV positive, should the ICD-10-CM code Z21 be reported? What about if they document the patient is HIV positive with an HIV-related illness—would that be reported with ICD-10-CM code B20?
Q: We recently had a patient with a history of diabetes admitted with gangrene of the left second toe. Can you review any guidance related to ICD-10-CM coding and documentation for a case like this?
