Basic of ICD 10 code for Aortic Aneurysm An aneurysm is a localized abnormal dilation of blood vessels. Aneurysms can grow large and rupture or dissect. Aneurysms are classified primarily according to their location and, in some codes, whether rupture is present, such as: Heart (I25.3) Coronary artery (I25.41) Pulmonary artery (I28.1) Cerebral (I67.1) Thoracic aorta (I71.1- and I71.2-), which is further specified as ascending aorta, aortic arch, descending aorta, or unspecified thoracic aorta Abdominal aorta (I71.3- and I71.4-), which is further specified as pararenal abdominal aorta, juxtarenal abdominal aorta,…
Read MoreCoding guide for Emergency Department (CPT code 99281-99285)
Basics of ED CPT code 99281, 99282, 99283, 99284 and 99285 The emergency department is defined as an organized, hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention. It must be available 24 hours per day. Any physician seeing a patient registered in the emergency department may use emergency department visit codes. It is not required that the physician be assigned to the emergency department. No distinction is made between new and established patients in the emergency department. E/M services in…
Read MoreCPT Modifier 79, 78 and 58 : Secret Coding tips
Basics of CPT Modifier 79, 78 and 58 Reporting procedures and services performed in the outpatient setting may create a challenge for coders when a return to the operating room for a related or unrelated procedure or service becomes necessary. There are different modifiers used for outpatient setting like 59, 76, 77, 58, 78, 79 etc. but each one of them has to be used very carefully. Now we have new modifiers XE, XP, XS and XU along with 59 modifier for providing more specific information about the procedure performed.…
Read More76 Modifier : Coding Guidelines for coders
Basics about 76 modifier As per my knowledge and experience, Modifiers play a very important role in Medical coding. Modifiers are very used when there is a modification in the procedure performed. Modifiers are very important for Clearing CPC certification exam as well. There will at least one question about 76 Modifier, Modifier 59 and other modifiers. It is one of the most commonly used modifier in outpatient setting. Modifier 76 is used for the procedure which are repeated on same day by same physician. This looks very easy to…
Read MoreCPT code 97110 & 97112: Coding Guide for Coders
Basics of CPT code 97110 & 97112 The CPT code 97112 procedure requires direct one- on -one patient contact by a physician or therapist. The descriptor for this procedure reflects 15-minute intervals. If a procedure lasts more than 15 minutes, the CPT code can be reported for each 15-minute interval. CPT code 97112 Neuromuscular Re-education includes activities that facilitate re-education of movement, balance, posture, coordination, and proprioception/kinesthetic sense. You would include time spent kinesiotaping in this category as well as performing stabilization exercises, facilitation or inhibition, desensitization, ergonomic training, improving…
Read MoreCoding guide for CPT code 99441, 99442 & 99443
Description of CPT code 99441, 99442 & 99443 Telephone E/M services are provided to a patient, parent, or guardian and do not originate from a related E/M service within the previous seven days and do not lead to an E/M service or procedure within the next 24 hours or soonest available appointment. Telephone services are non-face-to-face encounters originating from the established patient for evaluation or management of a problem provided by a qualified clinician. The problem may not be related to an E/M encounter that occurred within the previous seven…
Read MoreDementia ICD-10 CM coding Guide for coders
Basic information about ICD-10 CM code for Dementia Dementia is characterized by the development of multiple cognitive deficits such as memory impairment and cognitive disturbances including aphasia, apraxia, and agnosia. The ICD-10-CM classifies dementia (categories F01, F02, and F03) on the basis of the etiology (i.e., vascular, other diseases classified elsewhere, unspecified) and severity (i.e., unspecified, mild, moderate, or severe). The severity level should only be assigned on the basis of provider documentation, unless otherwise instructed by the classification. When a patient admitted to an inpatient acute care hospital or other inpatient facility…
Read MoreCoding tips for Closed Fracture Treatment CPT codes
Basics of Closed Fracture treatment CPT codes When a patient is initially treated for a traumatic fracture, there are four typical methods of care that are orthopedic physician may provide: Closed reduction is a non-surgical manipulation of a fractured bone to restore the bone to normal anatomic alignment Percutaneous fixation involves the placement of a stabilizing device such as rod, plate, multiple wires, pins, or screws across a fractured bone, typically under imaging guidance. Open reduction with internal fixation (ORIF) is an incisional procedure to realign and fixate separated bone…
Read MoreBreast Procedure and Diagnosis coding skills
Sometimes unusual pathology cases make the best learning tools. Here’s an instance that provides lots of opportunities to illustrate principles for breast procedure coding. And because the case deals with a breast implant related condition that clinicians are just beginning to define and understand, this case allows you to learn about a new diagnosis code, too. Following is a layout of the case from background to diagnosis. Background: Patient with 3-year old breast implant presents with pain and hardening in upper outer quadrant of right breast. Prior cytology results indicated…
Read MoreUrethral Catheterization CPT Code 51701, 51702 & 51703 Coding tips
Basic about urethral catheterization CPT code Urinary catheters are used when patient is unable to empty his or her bladder. If the urine is retained in bladder, pressure is developed in the kidney. Such pressure can lead to harmful disorder like kidney failure. The urinary catheter has a tiny balloon attached at the end. When the catheter is placed in bladder, the balloon is inflated and it helps to keep it stable and immobile. When to remove the urinary the catheter balloon is deflated and the catheter is removed. Urethral…
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