- A patient is documented as having hypertension, end-stage renal disease, and diastolic congestive heart failure. The patient receives dialysis. How is this coded?
A. I13.2, N18.6, I50.30, Z99.2
B. I13.2, N18.6, I50.30
C. I13.2, N18.5, I50.30
D. I13.2, N18.9, I50.30Rationale:ICD-10-CM Official Guidelines for Coding and Reporting direct coders to use a hypertension code from category I13.- Hypertensive heart and chronic kidney disease when documentation states the patient has hypertension, chronic kidney disease, and heart failure. Per the Guidelines, use codes I13.2- Hypertensive heart and CKD, stage 5 or ESRD with heart failure, N18.6- ESRD, and I50.30- Diastolic (congestive) heart failure. Since it’s also mentioned that the patient is receiving dialysis, the Guidelines also instruct coders to add Z99.2- Dialysis status. Add codes for any additional coexisting conditions noted in the documentation such as dialysis, kidney transplant, diabetes, etc.
2. A patient with hypertension, stage 2 chronic kidney disease, and heart failure presents to their medical provider for a check-up. The provider documents that the patient’s hypertension is not related to chronic kidney disease or heart failure. How is this coded?
A. I10, N18.2, I50.9
B. I13.0, N18.2, I50.9
C. N18.2, I50.9, I13.0
D. Query provider for clarification
Rationale: Though the three conditions have a causal relationship, coding guidelines direct us to use code I10 if the provider clearly states the conditions are unrelated.
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3. A patient is admitted for aortic valve replacement secondary to BAV and nonrheumatic aortic valve stenosis. What is the proper code assignment for BAV and aortic valve stenosis?
A. I35.0, Q23.81
B. I35.0
C. I35.0, Q23.8
D. Q23.81
Rationale: Assign code I35.0 Nonrheumatic aortic (valve) stenosis, along with code Q23.81 Bicuspid aortic valve, when aortic stenosis develops in a patient with bicuspid aortic valve (BAV).
4. An ophthalmologist performed a dilated retinal eye exam on a patient, as well as indocyanine-green angiography. The interpretation and report performed by the ophthalmologist confirmed diagnosis of early dry AMD of the patient’s right eye. How is this encounter coded?
A. 99240, H35.3111
B. 2022F, 92240, H35.321
C. 2022F, H35.31
D. 2022F, 92240, H35.3111
Rationale: Screening tests usually include the Amsler grid and a dilated retinal exam (2022F Dilated retinal exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy (DM)). If age-related macular degeneration (AMD) is suspected, a dye-injection test (CPT 92240 Indocyanine-green angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral) may be ordered. ICD-10-CM coding depends on documentation. You might start out with H35.3- Degeneration of macula and posterior pole and a family history of AMD (H35.5- Hereditary retinal dystrophy). If documentation supports the type of AMD, however, you may be able to code with more specificity. For example, early dry AMD of the right eye is coded with H35.3111 Nonexudative age-related macular degeneration, right eye, early dry stage, and bilateral wet AMD with active choroidal neovascularization is coded with H35.3231 Exudative age-related macular degeneration, bilateral, with active choroidal neovascularization.
5. An established Medicare patient sees his primary care practitioner for medication management. While there, he also receives a flu shot (IIV3 VACC NO PRSV 0.5 ML IM). What are the procedure codes for this visit?
A. 9921x, 90471, 90656
B. 9921x, G2211
C. 9921x-25, G2211, 90656, G0008
D. 9921x-25, 90656, G0008
Rationale: In the 2024 Medicare Physician Fee Schedule (MPFS) final rule, the Centers for Medicare & Medicaid Services (CMS) was adamant that G2211 was not payable when the associated evaluation and management (E/M) visit was appended with modifier 25 Significant, separately identifiable E/M service. After hearing from the medical community, however, CMS changed its policy in the 2025 MPFS final rule to allow payment for add-on code G2211, when applicable, when the E/M base code (99202-99205, 99211-99215) is reported by the same practitioner on the same day as an initial preventive physician examination or annual wellness visit; a vaccine administration (90656, G0008); or any other Medicare Part B preventive service. The appropriate ICD-10-CM codes should also be billed, including Z23 Encounter for immunization and the patient’s condition being medically managed by the practitioner.
