In ICD-10-CM coding, terms like ‘probable,’ ‘suspected,’ or ‘likely’ are not considered definitive diagnoses for coding purposes. The correct action is to initiate a provider query to obtain clarification. This ensures the medical record accurately reflects the provider’s intent and supports accurate code assignment, which is essential for compliant billing and quality data.

CPT and ICD-10-CM guidelines require that diagnostic tests be linked to the diagnosis justifying the medical necessity of the test. The metabolic panel was performed to manage the diabetes, not the acute bronchitis. Therefore, the diabetes code (E11.9) should be reported as the primary diagnosis for the lab service to correctly demonstrate medical necessity.

According to ICD-10-CM coding conventions, when a definitive diagnosis has been established, you code that diagnosis. Signs and symptoms that are integral to the disease process (like chest pain with costochondritis) are not coded separately. Therefore, only M94.0 (Costochondritis) is assigned. Coding the symptom in addition would be considered unbundling.

For established patient office visits (99211-99215), code selection can be based either on the level of Medical Decision Making (MDM) OR total time. The scenario states MDM is moderate complexity, which meets the criteria for 99214. The 28 minutes of total time also meets the 99214 threshold (30-39 minutes for established patients). Since both elements support 99214, it is the correct code.

A personal history of a condition that is no longer present and not receiving treatment is coded using the Z85.- category (Personal history of malignant neoplasm). In this case, Z85.3 (Personal history of malignant neoplasm of breast) is appropriate. This information is relevant to the patient’s overall health status and risk factors, even during a wellness visit, and should be reported as a secondary diagnosis.

‘Urosepsis’ is a non-specific term indicating sepsis originating from a urinary tract infection. Per ICD-10-CM guidelines, sepsis due to a specified infection requires two codes: first, the code for the systemic infection (sepsis, such as A41.9 or a more specific code if the organism is known), followed by the code for the localized infection (the UTI, N39.0). This accurately represents the causal relationship.

Modifier -59 (Distinct Procedural Service) is used to identify procedures/services that are not normally reported together but are appropriate under the circumstances. It indicates that a procedure was separate and distinct from another service on the same day by a different site, different session, different procedure, or different lesion. This helps bypass National Correct Coding Initiative (NCCI) edits when appropriate.

Modifier -22 (Increased Procedural Services) is used when the work required to provide a service is substantially greater than typically required. Documentation must support the substantial additional work and the reason for it (e.g., increased intensity, time, technical difficulty, severity of patient’s condition). The described adhesions and extra 45 minutes of dissection are classic indicators for the appropriate use of modifier -22.

The Uniform Hospital Discharge Data Set (UHDDS) defines the principal diagnosis as ‘that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.’ The patient was admitted *for* acute respiratory failure *due to* pneumonia. Therefore, the respiratory failure (J96.01) is the condition that occasioned the admission and is sequenced first, followed by the pneumonia.

In ICD-10-CM coding, terms like ‘probable,’ ‘suspected,’ or ‘likely’ are not considered definitive diagnoses for coding purposes. The correct action is to initiate a provider query to obtain clarification. This ensures the medical record accurately reflects the provider’s intent and supports accurate code assignment, which is essential for compliant billing and quality data.0