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  1. M

    Wiki DM & Hyperlipidemia

    I know this is a very old post but the real question is what is considered "other complication" and what is consider "circulatory complication" etc etc etc. I dont think the intent is that every single possible choice be listed, hence the stated "circulatory complication" and "other complication"
  2. M

    Wiki egd with botox injection esophagus

    when an egd and balloon esophageal dilation is performed as well as botox injection of esophagus, is it appropriate to use a modifier to unbundle those procedures if they are both performed of esophagus? i would think unbundling with modifier 59 would only be appropriate for a different site.
  3. M

    Wiki laparoscopic lysis of adhesions only

    If laparoscopic lysis of adhesions is the only procedure performed can we code 49329 without the documentation of"extensive". Does that rule only appy when we are trying to code adhesiolysis in addition to another procedure?
  4. M

    Wiki is 52281 for "through the scope"

    yes, 52281 wouldn't be coded with 52281 or the dilation code but what I am asking is 52281 coded only when the dilation is performed "through" the scope? If the scope is inserted and then removed and then the dilation is performed are we still to code 52281 when the scope has been taken out?
  5. M

    Wiki is 52281 for "through the scope"

    If patient does have urethral stricture, and sound dilation is performed "prior to" the cystoscope being inserted is it appropriate to code 52281 or is this code only appropriate for "through the scope" dilation????
  6. M

    Wiki diabetes and glaucoma

    We now assume a relationship between certain conditions and diabetes if they are listed under "diabetes with" in icd10. Under "diabetes with" glaucoma is not listed however opthalmic complication is listed. Which gives you code E11.39. When you look up E11.39 in the tabular it instructs you to...
  7. M

    Wiki Coding clinic clarification on causal conditions

    I agree, it is clearly stated that "with" means the same as "due to". If diabetes is documented anywhere in the record and one of the conditions listed under "with" is also stated in the record, even though the provider did not link them, the coder is to link them.
  8. M

    Wiki 52000 vs 52281 please help!!

    Does 52281 apply when the dilation is not performed "through the scope"?
  9. M

    Wiki 52281

    in 52281, cysto with dilation, is this referring to dilation done "through the scope"?
  10. M

    Wiki urethral dilation with sound prior to insertion of scope for urethral stricture

    I do not have one at this time to send but yes 52000 and 53601 bundle. Basically what I am asking is 52281 referring to a "through the scope" dilation? if the dilation is done with sounds prior to insertion of the scope and then a cysto is separately done I would only be coding 52000 and not...
  11. M

    Wiki urethral dilation with sound prior to insertion of scope for urethral stricture

    patient has chronic urethral stricture due to morbid obesity, he has dilations done on a regular basis, The doctor states he used sounds to dilate the urethral stricture and then following this the scope is inserted and cystoscopy is performed. Does 52281 apply in this case or would the dilation...
  12. M

    Wiki coding polyps with only documentation of cm

    I should have been more specific. When coding in pcs you are required to know the specific colon site. So if all you have documented is centimeters would it be ok to use a diagram to establish the specific site based on centimeters?
  13. M

    Wiki Diagnosis coding-If the patient is

    you can't code anxiety unless the physician documented that condition. If it is listed under the chronic condition list then you could code it.
  14. M

    Wiki coding polyps with only documentation of cm

    Is it ok to code the specific site of colon polyps and the polypectomy procedure to the specified site of ascending, transverse, sigmoid etc if the physician only documented the location using centimeters?
  15. M

    Wiki dental procedure codes in pcs

    well, outpatient hospital procedures always have(had) icd-9 procedure codes attached, not just inpatient so I would imagine the same would apply for pcs
  16. M

    Wiki dental procedure codes in pcs

    how do you code dental procedues in pcs such as crowns, restorations?
  17. M

    Wiki op note dx vs path report dx

    ok, that is what I do but someone told me otherwise and I wanted to clarify. If the colonoscopy op note states colon polyps were removed but the path does not show polyps then what? Don't code polyps even thought doctor stated they are polyps and polypectomy was performed?
  18. M

    Wiki op note dx vs path report dx

    On EGD report the doc performs biopsies of stomach and he states patient has antral gastritis but path report states reactive gastropathy, do you only code from the path or code both?
  19. M

    Wiki CPC exam - The cpc exam needs to be revised

    The cpc exam needs to be revised. It is entirely multiple choice and the percentage required to pass is too low. Therefore, the coding profession has been flooded with thousands of people who may not really be quallified for a coding job but they get one because they have passed the cpc exam. It...
  20. M

    Wiki Clinical documentation specialist

    What actually happens at my facility is the CDI attempts to code the chart. Just slapping on codes. Then it goes to the coder who has to sort through everything that was coded by the CDI and correct it all and prepare necessary queries that should have been initiated by the CDI. Then the coder...
  21. M

    Wiki Clinical documentation specialist

    My other question is, if a condition is documented in the record that isn't supported clinically, should it just be left out without verification with the provider?
  22. M

    Wiki Clinical documentation specialist

    I am wondering if anyone out there has any good information for me to clarify what the role of the clinical documentation improvement specialist really is. I work for a facility that has a CDI program and let me try and briefly explain what they do. They are all nurses first off. What they do is...
  23. M

    Wiki abscess drainage

    patient seen in ER for toe abscess. Physician numbs the toe with lidocaine and uses mosquito forceps to enlarged the opening for drainage. Should this be coded as a an I&D, and I&D with a reduced service modifier since no real incision is made or just be part of E/M?
  24. M

    Wiki abnormal findings

    the reason I ask is I was told not to code abnormal findings unless they state "abnormal" which I didn't feel was correct. If the term increased or decreased or any other findings is documented that there is no code for then I always used one of the abnormal findings codes for radiology. Now I'm...
  25. M

    Wiki abnormal findings

    when coding one of the abnormal findings codes for radiology does the word abnormal actually have to be stated or can those codes be used when something is documented that doesn't have a code but is known to not be normal?
  26. M

    Wiki coding radiology-Can someone please

    I agree with what you are telling me. The reason I was asking is that I am being told by person doing my reviews that I should only be coding the finding as primary if it is stated that it caused the symptom or it is stated in the order that they were ruling out what they ended up finding. I...
  27. M

    Wiki ordering dx and impression

    In reference to radiology coding, what is the correct way to select what will be listed as your primary dx? Should the primary be the same as the ordering dx unless the order states something is being ruled out? Also, does the word abnormal have to be used in order to use an abnormal finding on...
  28. M

    Wiki coding radiology-Can someone please

    How do I apply the rules: "If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not...
  29. M

    Wiki subtherapeutic INR

    how in the world do you code this? i always used abnormal coagulation profile but I am thinking that may not be correct since they don't really tell me that its abnormal.
  30. M

    Wiki grief with depression

    there is an excludes note under 311 for 309.0. When trying to code both an edit appears stating not to code the 311 which makes perfect sense to me. Seems like the exlcudes note should be under 309.0
  31. M

    Wiki multiple breast cysts

    what code do you use for multiple breast cysts? there is a code for "solitary" but not multiple.
  32. M

    Wiki multinodular goiter with hypothyroidsm

    documentation states patient has multinodular goiter and hypothyroidsm. There is a note under 241.1 that says "no clinical hypothyroidism".What does that mean?
  33. M

    Wiki coding radiology-Can someone please

    ok, I guess my biggest question is, How do you determine if the reason for the test should be sequenced as the primary dx or the findings? For example, if the ct of the abdomen is being performed for abdominal pain and the impression states fatty liver, diverticulosis, and hiatal hernia do you...
  34. M

    Wiki coding radiology-Can someone please

    Can someone please tell me the real, true, 100% correct rules on coding from radiology reports. When you have your order and it contains a reason for the test and also a symptom would you leave off the symptom as you would in all other coding scenarios? Is it appropriate to code from the...
  35. M

    Wiki Cdi

    Of course the majority of people on this site are coding outpatient, but I am curious how many inpatient coders will respond. The CDI program is designed to help the hospital improve its documentation and coding. It is my understanding that the CDI is to analyze the record prior to the coder...
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