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The AHA Central Office has received several questions whether sepsis with any acute organ dysfunction is assumed to be linked by the term “with” or if the physician must directly link it with t...
Code assignm...
Please advise which guidelines apply when coding sepsis with organ dysfunction. Should we follow the coding convention “with” and assume a causal relationship? Alternatively, are the chapter sp...
Provider doc...
A 79-year-old male with type 2 diabetes mellitus presented due to acute cellulitis of the left lower leg. The patient was admitted and started on broad-spectrum antibiotics. When assigning the diab...
In order to ...
Could you please clarify the correct use of the diabetes subentry with “skin complication NEC?” Would the correct application of the entry with skin complication only pertain to provider docume...
The “with...
A 71-year-old male with type 2 diabetes mellitus presented to the Emergency Department with a swollen gangrenous right foot that was diagnosed as gas gangrene. Does the Alphabetic Index subentry fo...
Assign codes...
There appears to be an increase in physicians documenting uncertain diagnoses on the discharge summary that have actually been ruled out. Some physicians are using the concept of “uncertain diagn...
The ICD-...
A patient is admitted for brachytherapy due to cervical cancer. Intrauterine tandem and ovoids are placed and brachytherapy is provided. When coding encounters for brachytherapy, should code Z51.0,...
Assign code ...
A 52-year-old woman with squamous cell carcinoma of the cervix presents for her first brachytherapy treatment with intrauterine tandem and ovoid placement. The vagina was prepped and draped, a tand...
Assign the f...
The patient was admitted for placement of a Watchman™ left atrial appendage device in the os of the left atrial appendage. Under fluoroscopic and echocardiographic guidance, the device was advanc...
In this case...
The patient underwent endoscopy due to upper gastrointestinal bleeding. A large duodenal ulcer with adherent clot was found and injected with epinephrine for hemostasis and 3 clips were placed. Is ...
When a patie...