Q: We are currently coding a chart for an acute kidney injury which has the baseline serum creatinine and urine output missing from the...Read More »
Q: If the principal diagnosis is pneumonia, do I need to also code the symptom dyspnea...Read More »
Q: If a patient is admitted for anemia related to a malignancy and is treated only for...Read More »
Q: Sometimes I confuse the secondary diagnosis for the primary diagnosis. Do you have any tips for me to help me discern...Read More »
Q: I’m running into a big problem with the nursing documentation. The nursing notes...Read More »
Q: At my institution, we typically do not capture the pleural effusions noted and...Read More »
Q: We have started receiving rejections for ED claims when the service involves removing impacted cerumen. We are reporting CPT® code...Read More »
Q: When would respiratory failure be used as a principal diagnosis?...Read More »
Q: What is the best way to document time spent by physicians performing procedures? The CPT® codes state a vague time amount but the...Read More »
Q: I am having difficulty understanding “late effects.” The statement of a “condition or nature of the late effect is sequenced first,”...Read More »