Ask An Expert: MRA
| Q: | Our patient has SSS & a pacemaker. How do I code the pt’s condition correctly? |
| A: |
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 |
| Q: | 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? |
| A: |
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 |
| Q: | When an MRA patient has several diabetic manifestations, do I need to report all the diabetic codes even though there is a hierarchy? |
| A: |
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 |
| Q: | My physician documents diabetes as follows: DMII/CKD III/Peripheral neuropathy. What is the correct way to code this? |
| A: |
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 |
| Q: | 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? |
| A: |
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 |
| Q: | The doctor documented that a patient has DM with glaucoma. How do I code this for MRA purposes? |
| A: |
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 |
| Q: | My PCP documented and coded breast cancer (ICD-10-CM code C50.-) for a patient who had a mastectomy three years ago and is receiving Tamoxifen. He was told that if the patient was receiving treatment, he could code active cancer. Is this correct from an MRA standpoint? |
| A: |
Yes and no. When a patient has an active cancer, regardless of whether he or she is receiving treatment, the primary cancer ICD-10-CM code is used. The scenario you presented isn’t quite so clear. Breast cancer has a treatment phase … Read Full Post |
| Q: | The PCP documented “aortic atherosclerosis.” How do I code this for MRA purposes? |
| A: |
Atherosclerosis of the aorta is a common condition in the elderly and the ICD-10-CM code is I70.0. However, it’s important to distinguish between atherosclerosis of the vessel (which is a risk adjusted diagnosis) and a valve (ICD-10-CM code I35.8, which … Read Full Post |
| Q: | 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? |
| A: |
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 |
| Q: | A specialist’s consultation report came back three weeks after our patient had a face-to-face visit with the PCP, and revealed some new risk adjusted diagnoses. Can my PCP make an addendum and report them? |
| A: |
Probably not. An addendum is used when the patient was assessed for a condition during the visit and the PCP needed some additional information, to be received very timely, in order to make a definite diagnosis. Addenda are not used … Read Full Post |