Key ICD-10-CM Guidelines for Infectious Diseases Code the Confirmed Diagnosis Only code confirmed infections when documented by the provider Terms like “suspected” or “rule out” are not coded as confirmed in outpatient settings Identify the Causative Organism Many...
What is a PICC Line? A Peripherally Inserted Central Catheter (PICC) is a long, flexible catheter inserted through a peripheral vein (typically in the arm) and advanced into a central vein (usually the superior vena cava). Common uses: Long-term IV antibiotics...
Hyperbilirubinemia - 4-day-old Medical Specialty: Emergency Room Reports Description: 4-day-old with hyperbilirubinemia and heart murmur HISTORY: The patient is a 4-day-old being transferred here because of hyperbilirubinemia and some hypoxia. Mother states that...
Medical Coding for Robotic-Assisted Procedures Robotic-assisted surgery continues to expand across multiple specialties, and while many coders are taught “there are no codes for robotics,” that statement is only partially true. The reality is: CPT (physician coding):...
Medical Coding Standard Operating Procedures (SOPs): Guidelines and Tips Standard Operating Procedures (SOPs) are essential in medical coding to ensure accuracy, compliance, consistency, and efficiency across all coding processes. Whether you are working in a...
Medical Coding Spinal Facet Joint Interventions: Guidelines & Tips Spinal facet joint interventions are commonly performed for both diagnostic and therapeutic management of chronic back and neck pain. For medical coders, these procedures can be challenging due to...
Ecstasy Ingestion - ER Visit Medical Specialty: Emergency Room Reports Description: Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy...
Medical Coding Clarified: How to Interpret NCV Reports (Nerve Conduction Velocity) for Accurate Coding Nerve Conduction Velocity (NCV) studies are commonly performed alongside EMG testing to evaluate nerve function. For medical coders, one of the most important — and...
Helpful Tools to Study for the AAPC CPC Exam (Apps, Resources & More) Preparing for the AAPC CPC exam requires more than just reading your books—you need efficient, targeted tools that help reinforce concepts, improve speed, and simulate the real exam environment....
Airway Compromise & Foreign Body - ER Visit Medical Specialty: Emergency Room Reports Description: The patient is a 17-year-old female who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was...