Medical Coding Simplified

After the test, what happens…. Spend a quiet moment alone . After you finish taking the test, do not immediately talk to your friends about the test. Instead, take a quiet walk--outside if possible. Calm down and breathe deeply. Remember that you did the best you could in the present circumstances. For example, say to yourself: I prepared as well as I could with the time and resources I had. I demonstrated the knowledge I hold in the present moment. I am proud of my work. Do not compare answers. After you finish taking the test, do not ask your friends what their answers were. They could be wrong or right so comparison is not helpful. Additionally, you might stress over not matching their answers but be right all along. Instead, congratulate yourself for the things you did well and learn from the areas where you think you could have done better. Visit a good friend. After an exam, it is nice to meet with a friend, preferably not one who has taken the exam. You...

Page 19 – ICD-10 When the provider documentation refers to use, abuse and dependence of the same substance, only one code should be assigned to identify the pattern of use based on the following hierarchy: If both use and abuse are documented, assign only the code for abuse If both abuse and dependence are documented, assign only the code for dependence If use, abuse and dependence are all documented, assign only the code for dependence. If both use and dependence are documented, assign only the code for dependence. ICD-10 CM DIAGNOSIS CODE DESCRIPTION F17.200 Nicotine dependence, unspecified, uncomplicated F17.201 Nicotine dependence, unspecified, in remission F17.210 Nicotine dependence, cigarettes, uncomplicated F17.211 Nicotine dependence, cigarettes, in remission F17.220 Nicotine dependence, chewing tobacco, uncomplicated F17.221 Nicotine dependence, chewing tobacco, in remission F17.290 Nicotine dependence, other tobacco product,...

It’s one of the most important questions coders must ask while using ICD-10: Is there a single combination code that fully identifies the patient’s relevant conditions, or is it necessary to report two separate codes? The volume of combination codes in ICD-10 has increased, making it imperative for coders to be alert and aware of instances in which combination codes are applicable. Defining Combination Codes The ICD-10-CM Official Guidelines for Coding and Reporting describe combination codes as those used to classify the following: •         Two diagnoses •         A diagnosis with an associated secondary process (manifestation) •         A diagnosis with an associated complication Coders cannot — and should not — assign multiple diagnosis codes when a single combination code clearly identifies all aspects of the patient’s diagnosis. For example, say a pati...

Here are the three basic coding rules that you must adhere to when billing for Injection/Infusion services: Rule #1: Pay Attention to the Administration Route When you’re looking at the treatment note, you can first look for hints to proper coding by identifying the Route of Administration.  the Injection/Infusion CPT® codes fall into one of three major categories: 1. Intravenous Infusions (IV) 2. Intravenous Pushes (IP) 3. Injections (Sub-Q, IM) Don’t forget: The Centers for Medicare & Medicaid Services (CMS) regulations look at the way a drug is administered only as “the physical process by which the drug enters the patient’s body” – not whether a medical professional administers the drug or supervises the administration. But the administration route hierarchy isn’t the only one you need to understand for Injection/Infusion coding — there is another hierarchy for the type of agent that works in tandem with the administration one. Rule #2: Unde...