Ask An Expert: ICD-10
| Our patient has SSS & a pacemaker. How do I code the pt’s condition correctly? | |
|
Sick Sinus Syndrome (SSS) is a condition in which the patient’s heart rhythm is disrupted; depending on the patient’s symptoms, he or she may receive a permanent pacemaker (PPM) to regulate the heart’s rhythm. In the past, SSS (I49.5) was … Read Full Post |
|
| My patient has PVD, atherosclerosis of the lower extremities, and an AAA, which are all in HCC 108. I was told we need to document all three conditions even though there is only one payment for each HCC. Do I really need to waste my time reporting all three conditions? | |
|
Yes, you do. The medical record is a legal document that must reflect all the conditions the patient has and their management. If the patient has all three conditions, and they are properly assessed and documented, they must all be … Read Full Post |
|
| When an MRA patient has several diabetic manifestations, do I need to report all the diabetic codes even though there is a hierarchy? | |
|
Yes, and the creation of combo codes in ICD-10-CM makes coding multiple diabetic manifestations much easier. (Check out our blog on Combination Codes) There are a few reasons why you should code them all, assuming they were all assessed at … Read Full Post |
|
| My physician documents diabetes as follows: DMII/CKD III/Peripheral neuropathy. What is the correct way to code this? | |
|
Assuming your provider is the last hold-out from an EMR conversion, and based on the way you wrote your question, the correct ICD-10-CM codes are: E11.22 N18.3 E11.40 Remember that you cannot infer a causal relationship between the diabetes and … Read Full Post |
|
| We attended an MRA training workshop and we were told that once a patient with an AAA has had surgery, we cannot code the aneurysm. We’re very confused! Is this correct? | |
|
It depends. (Don’t you just hate those answers?!) When an AAA is resected, the bulging section of the vessel is removed. After surgery, if the patient were to undergo an abdominal ultrasound, there will be no evidence of the aneurysm. … Read Full Post |
|
| The doctor documented that a patient has DM with glaucoma. How do I code this for MRA purposes? | |
|
Glaucoma can be a manifestation of a patient’s diabetes and the situation you describe would be coded as E11.39 and H42. (Remember that absent a specified diabetes type, the default is Type 2.) Although a lot of diabetics also have … Read Full Post |
|
| One of our patients was treated for breast cancer in 2007, and the PCP is reporting ICD-10-CM code C50.912. Is this correct? | |
|
In all likelihood, no. The coding guidelines for cancer state that “When the primary malignancy has been excised, no further treatment is directed to the site & there is no evidence of an existing malignancy,” the clinician must document ‘history … Read Full Post Tagged:
|
|
| My PCP has a habit of documenting a lot of conditions as “history of.” I was told that for a condition like CHF, I can code ICD-10-CM I50.9 when she documents “history of CHF.” Is this correct? | |
|
No. The term ‘history’ is actually used in two manners by clinicians. In one case, it means the patient had this condition in the past. It can also mean the patient has actually had the condition for some time and … Read Full Post |
|
| How should I prepare for ICD-10-CM? | |
|
From time to time, we hear about consultants scaring the daylights out of providers with horror stories about the transition to ICD-10. We disagree with that approach, although it’s important to have a healthy respect for any system that – … Read Full Post Tagged: ICD-10, prepare for ICD-10
|
|
| What exactly is ICD-10? | |
|
ICD-10-CM (based on the International Classification of Diseases, 10th edition, Clinical Modification) is a standard set of codes used for conveying a patient’s clinical profile, if you will. Defined codes are used primarily to facilitate the gathering of data, its … Read Full Post |
|