Q: We had a patient admitted with a negative COVID-19 test, but after being retested the patient had a positive COVID-19 result. Should we query the provider whether COVID-19 was POA?
Our coding experts answer questions about CPT documentation and coding for psychotherapy services, ICD-10-CM reporting for knee injuries, conducting chargemaster audits, and more.
Q: We are confused about which body part value in ICD-10-PCS should be captured for an incision and drainage (I&D) of a perianal abscess of the left buttocks because the physician documented both “perianal” and “left buttocks.”
Q: When two conditions are both present on admission, both meet definition to be the principal diagnosis (PDX), and are “equally treated,” my understanding is that the condition does not have to be "equally treated" in the sense of duration/frequency. Can you provide the actual verbiage of the coding rule and explain?
Our coding experts answer questions about CPT reporting for spinal decompression procedures, using medical decision-making to report E/M levels, and more.
Q: Was there an Excludes note change for subcategory G93.4- (other and unspecified encephalopathy) for fiscal year 2021? If so, how will it change any ICD-10-CM reporting and reimbursement for toxic encephalopathy and metabolic encephalopathy going forward?
Q: Are there any newly implemented fiscal year 2021 ICD-10-CM codes for spontaneous cerebrospinal fluid leaks (CSF)? Can you review any background and possible new codes for this disorder?
Our coding experts answer questions about reporting strokes and seizures in ICD-10-CM without pre-existing disorders, revenue cycle education for clinical staff, and more.
Q: Is there ICD-10-CM sequencing guidance for a patient who had a hemorrhagic stroke and then a seizure without a pre-existing seizure disorder? Would it be appropriate to report epilepsy, and are there any inclusion terms we should be aware of?
Q: What are the benefits to having coders review charts for appropriate capture of CCs and MCCs, and how can our coding team get started in this process?
Q: When might it be appropriate to report computer-aided mapping of the cervix uteri using 2021 CPT add-on code 57465 (computer-aided mapping of cervix uteri during colposcopy, including optical dynamic spectral imaging and algorithmic quantification of the acetowhitening effect)?
Q: We have an elderly patient admitted to our hospital who is also presenting with osteoarthritis (OA) of the right knee. How can we determine primary versus secondary OA, and how would it be reported in ICD-10-CM?
