Prior to October 1, 2016, the coma scale was only reported in conjunction with traumatic brain injuries, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. Coders should now be reporting the GCS when documented on any case where there is monitoring of the central nervous system regardless of the medical condition requiring the monitoring. The documentation of the coma scale may be found documented by other clinicians involved in the care of the patient (EMT, nursing) and not only by the physician. The physician must have documented the associated diagnosis (why the GCS is being addressed) such as encephalopathy, stroke, overdose, etc.Read More
A change has been made in how coders will report pressure ulcers when the stage of the ulcer changes during the admission. Per the ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 Page 51, if a patient presents with a pressure ulcer at one stage and during the admission it progresses to a higher stage, two separate codes would be reported. One for the site and stage of the ulcer on admission and another for the same ulcer and the highest stage reported during the admission.Read More
This is a change from ICD-9-CM diagnosis coding as we were instructed to code the symptoms only instead of both conditions when comparative/contrasting diagnoses were given as a secondary diagnosis.Read More
ICD-10-CM code Z95.0 is used to report the presence of a cardiac pacemaker without current complications. If the device is interrogated, code Z45.018 would be reported as it is no longer just the
presence of the device but attention to the device.
Pleural Effusion is common in patients with Congestive Heart Failure. This is usually minimal and requires no additional treatment than that given for the heart failure. Pleural Effusion should not be coded when only found as a radiological finding without the physician concurring with the finding and addressing it by one of the methods below.Read More
Root operation groups for the Medical and Surgical section share similar attributes. Below is a list that show each group and which root operations are included in the description (this is only for the Medical/Surgical section and the other sections will be addressed in a later document).Read More