I need an ICD 10 Diagnosis code for ROUTINE LABS only when a patient comes for a sick visit like HA and wants her/his labs tests as well.
These are my questions:
1. Can the dx of R93.0, abnormal findings on diagnostic imaging of skull and head, NEC, be reported. Please note: the attending does not address these findings and states the MRA is negative.
2. Can the TIA dx be reported if it is only found on the order? There are no other signs and symptoms in the medical record to support medical necessity for the MRA of the neck.
3. Should I query the provider?
When coding, consider all documented factors such as current and pre-existing conditions, trimester, and age. To capture pregnancy diagnosis codes correctly, documentation must specify the type and trimester of the pregnancy, as well as all related, present co-conditions in the mother. It’s not appropriate to use Z34.00 Encounter for supervision of normal first pregnancy, unspecified […]
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Today a fellow colleague has come to me asking for several thousands of dollars to be wrote off across our agency due to diagnosis. She is stating the the diagnosis expires after a year. Can you please confirm whether or not this is true? Do diagnosis expire after one year?
I have read the threatened abortion needs to have associated symptom like uterine cramps, abdominal pain, bleeding,…I am working in an IVF center (assisted reproducitve technique center) where physicians stated that threatened abortion can clinically be documented and thus coded without the above symptoms such as:
(1) Secondary Infertility where patient had multiple miscarriages and thus if pregnancy occurred, the patient is considered high risk pregnancy with history of infertility along with threatened abortion diagnosis.
Especially in the similar gestation weeks when she was aborted earlier.
(2) Primary Infertility with Multiple failed IVF cycle – Embryo Implantation failure. Thus if pregnancy occurred, the patient is considered high risk pregnancy with history of infertility along with threatened abortion diagnosis.
Another question about threatened abortion, if qualifying symptoms existed, can the physician document threatened abortion on sequential encounters (patient might experiences the symptoms in the first encounter and is under conservative management and not necessarily to have persistent symptoms in her next visit but physician documented in both visits threatened abortion).
Jibin zachariah CPC CPMA
I have read the coding rule for diabetes poorly controlled, out of control and hyperglycemia and the fact that uncontrolled phrase should not be used anymore but rather specifying the glycemic episode. But i have not seen in all those whether diabetes Mellitus with Hyperglycemia can be always documented by physician without having a hyperglyceminc episode or event whether symptoms level (dryness, urinary problem,…) or blood glucose level (showing elevation despite following diabetic regimen coarse,…) (and thus coded during the overall treatment/management coarse and follow ups). Some physicians have their clinical judgement that diabetes condition by default is out of control (hyperglycemic) and will be better controlled by the medications (oral+/-insulin). If hypoglycemia was the situation, this will certainly need documentation for the hypoglycemic event not like hyperglycemia. Thus, coder will always query the physician about the origin of diagnosis "diabetes with hypoglycemia".
Can you please let me know if query process will be needed when documentation just state poorly controlled without additional info.?
Jibin zachariah CPC CPMA
Please guide me on how to sequence the below diagnoses:
1. M54.14 – Intervertebral disc disorder with radiculopathy
2. M54.5 – Low Back pain
I have followed this sequencing. Kindly inform if I am right….