Looking for more information about Coding and Documentation Challenges for Key Diagnoses? BESLER’s Coding Manager Kristen Eglintine answers your questions from the recent webinar.
To watch Kristen’s Coding and Documentation Challenges for Key Diagnoses Webinar, click HERE.
- Can a final diagnosis be coded from an imaging report? e.g. reason for breast imaging dx: unspecified site left breast mass and imaging report indicated specified site.
In the inpatient setting, coders are not allowed to assign codes from diagnoses listed on diagnostic reports such as radiology, pathology, and echocardiogram (ECHO) even if a physician has signed the diagnostic report. However, according to a CC from 2013, first quarter; If the X-ray report provides additional information regarding the site for a condition that the provider has already diagnosed, it would be appropriate to assign a code to identify the specificity that is documented in the x-ray report.
- Does it matter if a patient is left or right handed?
Yes it does when coding sequele of a CVA. Codes from category I69, which pertain to the consequences of cerebrovascular disease, identify any hemiplegia, hemiparesis, or monoplegia by specifying the affected side as either dominant or non-dominant. If the affected side is not specified as dominant or non-dominant and the classification system does not provide a default, the following guidelines should be followed for code selection:
For ambidextrous patients, the default should be dominant.
If the left side is affected, the default is non-dominant.
If the right side is affected, the default is dominant. - How would you code Mitral Valve Annular Calcification with Aortic Valve and Tricuspid Valve Regurgitation? I05.8 and I08.2? Or just I08.8?
For Rheumatic disorders:
Rheumatic mitral valve annular calcifcation codes to I05.8
Aortic Valve and Tricuspid Valve Regurgitation codes to I08.2For Non-rheumatic disorders:
Mitral Valve Annular Calcification codes to I34.81.
Aortic valve regurgitation codes to I35.1
Tricuspid valve regurgitation codes to I36.1 - I’ve seen denial of cardioembolic cva post op cardiac procedure, the payer claimed the postoperative cva code was specific enough; however, if specific site of cva is documented, coded to most specific site of cva would be most appropriate, report both post op cva and cva at specified site. Is that correct? Thanks!
Yes, report both the post op cva and cva at specified site.
Related Resources
- WEBINAR: Coding and Documentation Challenges for Key Diagnoses Webinar (recording and slides)
- Coding and Documentation Challenges for Key Diagnoses Webinar [PODCAST]
