Q: When it comes to conditions not related to hypertension, is it sufficient to attribute the diagnosis to another etiology or does the provider need to specifically document that the congestive heart failure (CHF) is not due to hypertension?
Q: Can you explain where in the clinical documentation it would be acceptable to report from for hierarchical condition category purposes? Would you code from history of present illness, past medical history, active problem list, or the assessment?
Q: If a patient is admitted for anemia related to a malignancy and is treated only for anemia, the principal diagnosis goes to the malignancy. Could you still code for the malignancy as the principal diagnosis if the patient was treated for other conditions at the same time?
Q: Our team had a recent case that involved a small midline episiotomy which extended to a second-degree laceration which was repaired with 3-0 vicryl rapide sutures. Would we code the episiotomy and repair or just the repair, and why?
Q: Is CPT code 96416 (chemotherapy administration requiring use of portable pump) the same as HCPCS code G0498 (initiation of infusion of chemotherapy in office using portable pump)? Our facility is trying to determine if it would be appropriate to set up G0498 as a Medicare override for 96416.
Q: At my institution, all of our congestive heart failure exacerbations get at least one chest x-ray. Is that enough “diagnostic testing” to code the secondary condition in accordance to Coding Clinic ?
Q: For a ureteroscopy intended as a procedure with a biopsy and double-J stent, if the procedure ends when only the scope was placed before a biopsy was taken, could you just code ureteroscopy instead of coding it with the biopsy and the modifier-74 (discontinued outpatient hospital/ambulatory surgery center procedure after administration of anesthesia)?
Q: I can't distinguish between "code first" and "in diseases classified elsewhere.” Both are used with manifestations and both can't be sequenced as principal diagnosis and both need etiology codes, so what is the difference?
Q: We use an electronic system at our hospital, and find it is difficult to query a physician since we all have our own processes. Would you recommend having a set format for a query that is used electronically?