One way a physician query would be considered leading is by the introduction of a new diagnosis in the query. This creates a difficult situation for a coder when the clinical information in the record supports a specific diagnosis, but the physician fails to give the diagnosis. How is a coder to write a nonleading query in this situation?
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Aromatase inhibitors are used in the treatment of hormone receptor-positive, early, and metastatic breast cancer in postmenopausal women and, sometimes, in men with gynecomastia. They stop the production of estrogen in postmenopausal women by blocking the enzyme aromatase. The aromatase enzyme turns the hormone androgen into small amounts of estrogen in the body.
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HIA has previously discussed the coding of bronchoscopy with bronchoalveolar lavage (BAL). The coding of procedures performed via bronchoscopy has become complicated in ICD-10-PCS. The coder must now think about the objective of the procedure to assign the correct root operation, the correct body part being addressed, and the correct approach and whether or not the intent of any removal of tissue or fluid was diagnostic.
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