Operative Report Coding Tips
Diagnosis code reporting—Use the post-operative diagnosis for coding unless there are further defined diagnoses or additional diagnoses found in the body of the operative report. If a pathology report...
View ArticleHIV: ICD-10 Dx. Coding
HIV infection/illness is coded as a diagnosis only for confirmed cases. Confirmation does not require documentation of a positive blood test or culture for HIV; the physician’s diagnostic statement...
View ArticleCoding Uncertain Diagnoses
Accurate diagnosis coding is crucial for patient care and compliant, optimal reimbursement. In the outpatient setting, you should never assign a diagnosis unless that diagnosis has been confirmed by...
View ArticleFluid Administration Is Part of Operative Procedures
The CPT® codebook includes codes to report administration of fluids and drugs, but you should not report these administration services when they occur as part of an operative procedure. The National...
View ArticleThe Medicare Advance Care Planning Benefit
Since Jan. 1, Medicare covers advance care planning (ACP) as a separate service when provided by physicians and other health professionals (such as nurse practitioners who bill Medicare using the...
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