Codes Covered: ICD-10-CM Official Guidelines, Guideline I.B.2, Guideline IV.F.3, Guideline I.C.21.c, Guideline I.C.9.d, Guideline I.C.2.e.3, Guideline IV.H, Guideline I.B.9, Guideline I.C.4, Guideline I.C.4.a.3, Guideline I.A.15, Guideline I.C.9.a, Guideline I.A.13, J20.9 (acute bronchitis, unspecified), I10 (essential/primary hypertension), E78.5 (hyperlipidemia, unspecified; shown as incorrectly captured when not supported by M.E.A.T. and also contrasted with E78.2), E03.9 (hypothyroidism, unspecified; shown as incorrectly captured when not supported by M.E.A.T. and used in cancer example), I63 (acute stroke category), I63.- (acute stroke codes), I63.9 (cerebral infarction, unspecified), I69 (sequelae of cerebrovascular disease category), I69.3 (residual deficits following stroke category), I69.392 (facial weakness following cerebral infarction), Z86.73 (personal history of stroke without residual deficits), G45.9 (transient ischemic attack), I82.4 (acute DVT category), I82.5 (chronic DVT category), Z86.718 (personal history of other venous thrombosis and embolism), I82.402 (acute embolism and thrombosis of unspecified deep veins of left lower extremity, used in DVT example), I82.511 (chronic embolism and thrombosis of right femoral vein), I26 (acute pulmonary embolism category), I26.99 (other pulmonary embolism without acute cor pulmonale), I27.82 (chronic pulmonary embolism), Z86.711 (personal history of pulmonary embolism), Z79.01 (long-term/current use of anticoagulants), Z85 (personal history of malignant neoplasm category), D05.12 (intraductal carcinoma in situ of left breast), N18.2 (chronic kidney disease stage 2), Z90.12 (acquired absence of left breast and nipple), Z79.811 (long-term/current use of aromatase inhibitors), R07.9 (chest pain, unspecified), I20.9 (angina pectoris, unspecified; shown as not coded for suspected angina in outpatient/physician coding), R50.9 (fever, unspecified), R05.9 (cough, unspecified), R09.02 (hypoxemia), E78.2 (mixed hyperlipidemia), I50.2- (systolic/congestive heart failure; HFrEF; chronic systolic heart failure for HFmrEF when reduced EF is documented), I50.3- (diastolic/congestive heart failure; HFpEF; HFrecEF/HFimpEF coding), I50.4- (combined systolic and diastolic congestive heart failure), I50.20 (unspecified systolic/congestive heart failure), I50.30 (unspecified diastolic/congestive heart failure), I50.32 (chronic diastolic/congestive heart failure), I50.33 (acute on chronic diastolic/congestive heart failure), I50.810 (right heart failure, unspecified), I50.811 (acute right heart failure), I50.812 (chronic right heart failure), I50.813 (acute on chronic right heart failure), I50.814 (right heart failure due to left heart failure), I50.82 (biventricular heart failure), I50.83 (high output heart failure), I50.84 (end stage heart failure), I50-I50.9 (heart failure code range), I50.2-I50.43 (left ventricular failure/heart failure code range used with right, biventricular, and end-stage heart failure notes), E11 (type 2 diabetes default category), E11.0 (type 2 diabetes with hyperosmolarity), E11.1- (type 2 diabetes with ketoacidosis), E11.2- (type 2 diabetes with kidney complications), E11.3- (type 2 diabetes with ophthalmic complications), E11.4- (type 2 diabetes with neurological complications), E11.5- (type 2 diabetes with circulatory complications), E11.51 (type 2 diabetes with diabetic peripheral angiopathy without gangrene), E11.61 (type 2 diabetes with diabetic arthropathy), E11.62 (type 2 diabetes with skin complications), E11.63 (type 2 diabetes with oral complications), E11.64 (type 2 diabetes with hypoglycemia), E11.65 (type 2 diabetes with hyperglycemia), E11.69 (type 2 diabetes with other specified complication), E11.8 (type 2 diabetes with unspecified complication), E11.9 (type 2 diabetes mellitus without complications), E11.A (type 2 diabetes mellitus without complications in remission), E11.22 (type 2 diabetes mellitus with chronic kidney disease), E08-E13 with .51 (diabetes with peripheral angiopathy instruction), E10.22 (type 1 diabetes mellitus with diabetic chronic kidney disease), N18 (chronic kidney disease category), N18.30 (chronic kidney disease stage 3 unspecified), N18.31 (chronic kidney disease stage 3a), N18.4 (chronic kidney disease stage 4), N26 (contracted kidney category referenced in hypertension/CKD relationship guidance), I73.9 (peripheral vascular disease, unspecified), Z79.4 (long-term/current use of insulin), Z79.84 (long-term/current use of oral hypoglycemic drugs), Z79.85 (long-term/current use of injectable non-insulin antidiabetic drugs), I11- (hypertensive heart disease category), I11.0 (hypertensive heart disease with heart failure), I11.9 (hypertensive heart disease without heart failure), I12- (hypertensive chronic kidney disease category), I12.0 (hypertensive chronic kidney disease with stage 5 CKD or ESRD), I12.9 (hypertensive chronic kidney disease with stage 1 through stage 4 CKD or unspecified CKD), I13.0 (hypertensive heart and CKD with heart failure and stage 1 through 4 CKD or unspecified CKD), I13.10 (hypertensive heart and CKD without heart failure with stage 1 through 4 CKD or unspecified CKD), I13.11 (hypertensive heart and CKD without heart failure with stage 5 CKD or ESRD), I13.2 (hypertensive heart and CKD with heart failure and stage 5 CKD or ESRD), I51.4-I51.7, I51.89, I51.9 (heart conditions included in hypertensive heart disease relationship guidance), I51.81 (Takotsubo syndrome exception), G20- (Parkinson’s disease category), G30- (Alzheimer’s disease category), G10 (Huntington’s disease), G31.83 (Lewy body dementia), F02.8- (dementia in other diseases classified elsewhere), U09.9 (post COVID-19 condition), R43.8 (loss of smell/other disturbances of smell and taste), J96.10 (chronic respiratory failure, unspecified whether with hypoxia or hypercapnia), E66.3 (overweight), E66.01 (morbid/severe obesity due to excess calories), R63.6 (underweight), Z68 (body mass index category), Z68.29 (BMI 29.0-29.9, adult), Z68.42 (BMI 45.0-49.9, adult), Z68.1 (BMI 19.9 or less, adult), Z00.00 (encounter for general adult medical examination without abnormal findings), Z00.01 (encounter for general adult medical examination with abnormal findings), R74.01 (elevation of levels of liver transaminase levels), E53.8 (deficiency of other specified B group vitamins), E55.9 (vitamin D deficiency, unspecified), Z13.220 (encounter for screening for lipoid disorders; shown as captured but not correct for ordered future screening labs in the E/M example), Z13.1 (encounter for screening for diabetes mellitus; shown as captured but not correct for ordered future screening labs in the E/M example), Z12.5 (encounter for screening for malignant neoplasm of prostate; shown as captured but not correct for ordered future screening labs in the E/M example), Z79.02 (long-term/current use of antithrombotic/antiplatelets), Z79.891 (long-term/current use of opiate analgesic), F11.20 (opioid dependence; shown as not coded when opioid is prescribed and supervised for an underlying condition), Z95.0 (presence of cardiac pacemaker), C00-C14, C32-C34, C39, D00.0-, D02-, H65-, H66-, I10-I1A, I20-, I21-, I22-, I25-, I70-, J00-J99, K05-, K11-K14 (diagnosis categories that should use an additional code to identify tobacco use, history, or exposure when applicable).
Topics Covered: ICD-10-CM common audit findings, ICD-10-CM best practices, professional fee diagnosis coding, facility versus professional fee ICD-10-CM guideline consistency, documentation support for diagnosis coding, M.E.A.T. criteria, monitoring evaluating assessing/addressing treating, diagnosis support in the medical record, problem list coding pitfalls, history list coding pitfalls, medication list coding pitfalls, unsupported diagnosis coding, assessment and plan documentation, secondary diagnosis support, coding conditions pertinent to the visit, acute bronchitis coding example, hypertension coding example, hyperlipidemia without MEAT support, hypothyroidism without MEAT support, history of versus active condition coding, resolved condition coding, active diagnosis incorrectly reported, history Z code incorrectly reported, stroke versus history of stroke, acute stroke coding, stroke sequela coding, residual deficit following stroke, history of stroke without residual deficit, facial droop after CVA, acute CVA example, cerebral infarction coding, TIA versus acute stroke coding, PE and DVT active versus history coding, acute DVT coding, chronic DVT coding, venous thromboembolism history coding, prophylactic anticoagulant therapy, acute pulmonary embolism coding, chronic pulmonary embolism coding, anticoagulation therapy coding, INR follow-up coding, warfarin therapy coding, Xarelto therapy coding, cancer active versus history coding, current malignancy versus personal history of malignancy, active cancer treatment coding, adjuvant therapy coding, hormonal therapy for cancer, maintenance therapy for cancer, DCIS coding, mastectomy status coding, aromatase inhibitor use coding, Letrozole therapy coding, CKD stage 2 coding, uncertain diagnosis coding, possible diagnosis coding, rule-out diagnosis coding, outpatient uncertain diagnosis guidelines, physician coding outpatient rules, suspected angina coding, chest pain coding, symptom coding instead of suspected diagnosis, discharge summary diagnosis coding, possible pneumonia coding, suspected bacterial pneumonia, fever cough hypoxemia symptom coding, lack of specificity, incorrect code selection, coding to highest level of specificity, complete ICD-10-CM code assignment, required characters, required seventh character guidance, mixed hyperlipidemia coding, unspecified hyperlipidemia audit risk, heart failure coding, CHF definitions, ejection fraction, left ventricular failure, systolic heart failure coding, HFrEF coding, diastolic heart failure coding, HFpEF coding, combined systolic and diastolic heart failure coding, acute heart failure coding, chronic heart failure coding, acute on chronic heart failure coding, end stage heart failure coding, HFmrEF coding, mildly reduced ejection fraction coding, mid-range ejection fraction coding, HFrecEF coding, recovered ejection fraction coding, HFimpEF coding, improved ejection fraction coding, right heart failure coding, right heart failure due to left heart failure, biventricular heart failure coding, high output heart failure coding, community-acquired pneumonia with CHF example, acute on chronic diastolic CHF exacerbation, heart failure with recovered EF example, combination coding, assumed relationships in ICD-10-CM, combination code guidelines, diabetes combination codes, diabetes type default, type 2 diabetes default coding, diabetes with hyperosmolarity, diabetes with ketoacidosis, diabetes with kidney complications, diabetes with ophthalmic complications, diabetes with neurological complications, diabetes with circulatory complications, diabetic arthropathy, diabetic skin complications, diabetic oral complications, diabetic hypoglycemia, diabetic hyperglycemia, diabetes with other specified complication, diabetes without complications, type 2 diabetes in remission, diabetes medication status coding, insulin use coding, oral hypoglycemic drug use coding, injectable non-insulin antidiabetic drug use coding, type 1 diabetes insulin dependency exception, temporary insulin use coding, metformin coding, Ozempic coding, “with” convention coding, “in” convention coding, assumed causal relationships, diabetes with PVD coding, diabetes with peripheral angiopathy coding, diabetes with CKD coding, type 1 diabetes with CKD coding, CKD stage 3a coding, hypertension assumed relationships, hypertensive heart disease coding, hypertensive chronic kidney disease coding, hypertensive heart and chronic kidney disease coding, hypertension with heart failure, hypertension with CKD, hypertension with heart failure and CKD, Takotsubo syndrome exception, diabetes with CKD additional coding, systolic heart failure with hypertension example, CKD stage 3 with hypertension and diabetes example, CKD stage 4 with chronic diastolic heart failure example, hypertension and heart disease unrelated documentation, code first sequencing, etiology manifestation convention, use additional code notes, in diseases classified elsewhere, manifestation code sequencing, code also notes, code if applicable any causal condition first, dementia in other diseases coding, Parkinson’s disease with dementia, Alzheimer’s disease with dementia, Huntington’s disease with dementia, Lewy body dementia coding, post-COVID condition coding, loss of smell after COVID, chronic respiratory failure after COVID, BMI coding, body mass index coding, overweight BMI coding, morbid obesity BMI coding, underweight BMI coding, BMI codes with reportable diagnosis, BMI codes not assigned in pregnancy, preventive visit diagnosis coding, annual wellness visit diagnosis coding, screening diagnosis coding, Z00.00 versus Z00.01, general adult medical examination coding, abnormal findings on preventive exam, stable chronic condition in preventive visit, worsened chronic condition in preventive visit, uncontrolled hypertension on annual physical, screening code first-listed guidance, screening versus diagnostic testing, ordered screening labs during E/M visit, lipid screening coding, diabetes screening coding, PSA screening coding, missing secondary diagnosis coding, missing status codes, missing Z codes, anticoagulant therapy status, antiplatelet therapy status, atrial fibrillation with anticoagulation, coronary artery disease with stent and antiplatelet therapy, dual therapy monitoring, long-term medication use coding, opioid therapy status coding, chronic opioid use under medical supervision, prescribed opioid analgesic coding, opioid dependence not coded for supervised prescribed use, substance use disorder coding distinction, pacemaker status coding, complete heart block with pacemaker, pacemaker interrogation documentation, smoking status coding, tobacco exposure coding, tobacco history coding, tobacco use additional code requirements, oral cavity cancer tobacco status, respiratory cancer tobacco status, otitis media tobacco exposure status, hypertension tobacco status, angina tobacco status, myocardial infarction tobacco status, chronic ischemic heart disease tobacco status, atherosclerosis tobacco status, respiratory disease tobacco status, periodontal disease tobacco status, salivary gland and oral mucosa disease tobacco status, audit risk reduction, coder documentation review, accurate specific code selection, combination code selection, Z code selection, secondary diagnosis selection, medical coding compliance, ICD-10-CM coding education.
