Q: What advice can you give pertaining to clinical documentation requirements to properly report CPT codes for vaginal deliveries after cesarean procedures?Read More »
I have a question about coding human immunodeficiency virus (HIV) and HIV-related illnesses. If a physician documents a patient is HIV positive, should the chart be coded to Z21? What about if they document the patient is HIV positive with an HIV-related illness—would that be coded to B20?Read More »
I’ve been told that vasodilator therapy can be used to preserve renal function, but I’m having trouble understanding how. Could you explain it to me?Read More »
If Type 2 myocardial infarction (MI) and demand ischemia are both documented, should I code only Type 2 MI based on the Excludes 1 note found in the Tabular List under demand ischemia?
For example, a physician recently documented that a patient had elevated troponin, likely a Type 2 MI/...Read More »
We recently had a patient who was on oral Bactrim after a fracture who may have been non-compliant with his therapy but who indicates that he’s fully adherent to his medications. He was admitted for IV antibiotics, was given IV vancomycin, and was closely followed by the orthopedic physician....Read More »
Code T83.512, Nephrostomy tube catheter associated infection, leads to DRG 698-700. I understand this is not considered a hospital acquired condition (HAC), but is it still a catheter associated infection from a device?Read More »
In a case where the patient arrived in respiratory distress, was intubated, and was placed on a vent, treated with IV Solumedrol, HHN, IV antibiotics. The patient was admitted to the nursing unit on the vent. The physician documented acute hypoxic respiratory failure due to COPD exacerbation. I...Read More »