Q: When might it be appropriate to report CPT codes for multiday electroencephalograms (EEG)? In addition, should these codes be billed on the day of initiating or ending the EEG study?
Q: A patient receives Apligraf® (44 sq. cm) after subcutaneous wound debridement. Ten sq. cm is applied to a diabetic foot ulcer on the patient’s left heel and 20 sq. cm to an ulcer on the patient’s right ankle. What CPT codes would the facility use to report these services?
Q: I’m having trouble determining how to report an acute myocardial infarction (MI) for subsequent admissions occurring within four weeks of the initial MI in ICD-10-CM. Can you walk me through the process?
Q: A patient is diagnosed with Type 2 diabetes mellitus and arteriosclerotic peripheral artery disease (PAD). Can we report ICD-10-CM code E11.51 with a code from subcategory I70.2- to describe affected vessels?
Q: What CPT codes and modifiers would be used to report excisional debridement for removal of a 2x4-cm ulcer on a patient’s right buttocks with vacuum-assisted closure (VAC)?
Q: We have a patient admitted for COVID-19 who is now showing signs of cytokine release syndrome (CRS). Can you give our team more information on symptoms or clinical indicators for CRS as well as any ICD-10-CM coding advice?
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?
Q: Our coding team is having trouble understanding the different types of chronic respiratory failure (CRF) and knowing when to suspect its presence when it’s not specifically documented by our physicians. Can you please help us with this?
Q: What place of service codes and modifiers should be reported on physician claims for wound care services performed via telehealth during the COVID-19 public health emergency?
Our coding experts answer questions about chart audit focus areas, reporting separately payable E/M services with modifier -25, physician billing via telehealth, and more.
Q: CMS created a new MS-DRG for chimeric antigen receptor T-cell (CAR-T) therapies in the fiscal year (FY) 2021 IPPS final rule. Which ICD-10-PCS codes group to this new MS-DRG and does it qualify for an additional new technology add-on payment?
A patient with a history of hypertension sees a cardiologist for chest discomfort during exercise. The cardiologist completes an office visit and performs a cardiac stress test the same day. Would it be appropriate to report the visit using an E/M code with modifier -25?
Our coding experts answer questions about reporting modifier -58 for physicians and facilities, developing a charge capture audit process, and interpreting the 2021 E/M guidelines.
Q: We are having trouble with a case that involves an Implantation of a cardiac resynchronization therapy-pacemaker (CRT-P) with three leads and an envelope since our facility is new to using pacemaker envelopes. How should this procedure be reported in ICD-10-PCS?
Q: During an outpatient visit, a nurse reviews the patient’s medical history and a physician performs an examination in the presence of the nurse. If you adhere to the 2021 E/M guidelines and use time as the controlling factor for code selection, can you report one E/M code for these shared services?
Q: When would it be appropriate to report modifier -58 (staged or related procedure or service by the same physician during the postoperative period) for a procedure performed during the postoperative period?