Coding For Multiple E/M Services and an Injection

How strong are you at coding for multiple E/M services? Test your knowledge and see if you can determine the right way to code this scenario. Hint: There are CPT, HCPCS, and ICD-10-CM codes needed.      Question:  A 51-year old female patient is seen for a follow-up visit for her seronegative rheumatoid arthritis that […]

Making Assumptions About Hypertension and Heart Disease in ICD-10-CM

If you understand the FY 2021 ICD-10-CM coding guidelines involving causal relationships and the word “with” in the Alphabetic Index of the ICD-10-CM coding manual, coding for hypertension and heart disease in ICD-10-CM should not be difficult. Question:  Patient has congestive heart failure due to hypertension. Assign the ICD-10-CM code(s). Answer: I11.0, I50.9 Hypertension is another […]

Hypertension and Kidney Disease: Is There a Causal Relationship?

Question: A patient has hypertension, chronic kidney disease, renal failure, and is currently on dialysis. Patient is a former smoker who quit 3 years ago. Assign the ICD-10-CM codes. Answer: I12.0, N18.6, Z99.2, Z87.891 Hypertension, otherwise known as high blood pressure, is a leading cause of chronic kidney disease (CKD), according to kidney.org. Hypertension can […]

Craniotomy to Evacuate a Hematoma in CPT

Selecting the most specific code for a craniotomy to evacuate a hematoma in CPT comes down to the documentation, where the hematoma is located, and the approach taken to treat it.  Question:  A patient suffers an extradural hematoma in the supratentorial region of the brain, and the neurosurgeon performs a craniotomy to evacuate it. What CPT code […]