Respiratory FailureDefinition: Syndrome where the respiratory systems fail in either or both the gas exchange function or oxygenation and carbon dioxide elimination. Recognized as either hypoxemic or hypercapnic.Coding Considerations:Review the circumstances of...
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CDI Tips & Friendly Reminders: Poisonings vs. Adverse Reactions vs. Toxic Effects vs. Underdosing
Nov 15, 2023 | CDI, Coding + CDI, Coding Tips, Education & Training, News
Poisonings vs. Adverse Reactions vs. Toxic Effects vs. Underdosing DefinitionPoisoning: reaction to the improper use of a medication. This can include either:Wrong substanceWrong doseWrong personWrong Route of administrationTaken in combination of alcohol, illicit...
Coding Tip: Exagamglogene autotemcel
May 21, 2023 | Coding Tips, Education & Training
Exagamglogene autotemcel (Exa-cel) (aka CTX001™) is a genetically modified cell therapy that is used to increase fetal hemoglobin (HbF) in patients with sickle-cell disease (SCD) and transfusion-dependent beta-thalassemia (TDT). Exagamglogene autotemcel is an...
Social Determinants of Health (SDOH)
May 2, 2023 | Coding Tips, Education & Training
In 2021, Social Determinants of Health (SDOH) were added as risk factors to the CPT table used to determine the level of medical decision-making for evaluation and management (E/M) services provided during visits in an office or...
Refractory Angina Pectoris
Mar 7, 2023 | Coding, Coding Tips, Education & Training
New codes were assigned for refractory angina pectoris in FY 2023. These codes will differentiate refractory angina pectoris from other angina types and help ensure precise data collection coding. Chronic refractory angina pectoris is angina caused by irreversible...
Today’s Tip: Acute Respiratory Acidosis
Dec 29, 2022 | Coding, Coding Tips, Education & Training
New codes related to respiratory acidosis are now in place. Acute respiratory acidosis is now indexed to J96.02 (Acute respiratory failure with hypercapnia). Chronic respiratory acidosis is now indexed to J96.12 (Chronic respiratory failure with hypercapnia)....
Hepatic Encephalopathy
Nov 22, 2022 | Coding Tips, Education & Training
Code K76.82 We now have a code (K76.82) for Hepatic Encephalopathy for FY 2023. This includes documentation such as: "Hepatocerebral intoxication" and "Portal-systemic encephalopathy." It is important to note in the ICD-10-CM manual that we are to Code Also...
Today’s Tip: Hypercholesterolemia and Hyperlipidemia
Aug 30, 2022 | Coding, Coding Tips, Education & Training
Providers often use the terms hyperlipidemia and hypercholesterolemia interchangeably. Technically, hyperlipidemia is a high or elevated lipid/fat level in the blood. High blood cholesterol is a lipid disorder. As a result, when hyperlipidemia and hypercholesterolemia...
Today’s Tip: Light Meconium-stained Fluid
Aug 16, 2022 | Coding, Coding Tips, Education & Training
Meconium gives the amniotic fluid a greenish color. This is called meconium staining. Coding Clinic, Second Quarter 2022 clarifies ‘light meconium-stained fluid’ and how to code it. The presence of any meconium staining may indicate fetal distress, therefore code...
Coding Tip: The Eliquis Coding Conundrum
Aug 13, 2022 | Coding, Coding Tips, Education & Training
Eliquis can be used as an anticoagulant or an antithrombotic. When a patient is on Eliquis long-term, it can be a coding conundrum. As published in Coding Clinic, Second Quarter 2022, ICD-10-CM classifies Eliquis as an anticoagulant medication. Therefore, if...
Coding Tip: Metabolic Bone Disease (MBD)
Jul 29, 2022 | Coding, Coding Tips, Education & Training
This condition is commonly documented along with chronic kidney disease (CKD). MBD is a broad term used to describe a group of bone disorders of bone strength usually caused by mineral abnormalities such as calcium, phosphorus, vitamin D, or magnesium. As published in...
Coding Tip: Lupus
May 9, 2022 | Best Practices, Coding Tips, Education & Training
When Lupus (unspecified) is documented in a record, there is no default code. Therefore, it is important to have providers document this condition as precisely as possible. For instance, document SLE (systemic lupus erythematosus) instead and add any complications...