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A patient diagnosed with stenosis and degenerative spondylolisthesis underwent a 360-degree fusion. The provider documented Crescent PEEK interbody device, locally harvested autograft bone, some al...
Assign the f...
With the thoracic aortic valve repair (TAVR) procedures, the surgeons will document left heart cardiac catheterization. Occasionally they will mention a pressure or two, but no report that an actua...
TAVR is a mi...
Is there a guideline or rule that indicates that you should only use the medical record documentation for that specific visit/admission for diagnosis coding purposes? Does each visit or admission s...
Documentatio...
How is a total hysterectomy performed via an open approach coded? Is it appropriate to assign ICD-10-PCS codes for both the resection of the uterus and the cervix, when only a total hysterectomy is...
For a total ...
A patient, who had previously undergone modified radical mastectomy due to breast cancer, presented for insertion of a left breast tissue expander. The tissue expander was inserted into an expander...
For the plac...
How is a diagnosis of "chronic depression" coded?
...Assign code ...
Does ICD-10-PCS generally distinguish minimally invasive approaches to surgery?
...No. Neither ...
How would a documented diagnosis of “smoker” be coded in ICD-10-CM? Should it be coded as tobacco use or dependence?
...In ICD-10-CM...
Can you please define when to use nicotine dependence "uncomplicated", "in remission", "with withdrawal", "with other nicotine-induced disorders" and "with unspecified nicotine-induced disorders? T...
Although nic...
A patient, who has been a cigarette smoker for 20+ years, presents with chronic obstructive pulmonary disease (COPD). Would it be appropriate for the coder to assume that the COPD was caused by the...
No, it is no...