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Showing posts with the label Clinical Examples

Smoking Cessation Counselling

Smoking Cessation The following codes are used to report the preventive medicine evaluation and management of infants, children, adolescents, and adults. Modifier 25 should be added to the office/outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported. 99406 – Smoking and tobacco-use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes  99407 – Smoking and tobacco-use cessation counseling visit; intensive, greater than 10 minutes  Required Documentation Patient Current smoking details  Time  Counseling Content  Covered ICD Codes  F17.210 -  Nicotine dependence, cigarettes, uncomplicated F17.211 -  Nicotine dependence, cigarettes, in remission F17.213 -  Nicotine dependence, cigarettes, with withdrawal F17.218 -  Nicotine dependence, cigarettes, with other nicotine-induced diso

ICD-10 CM Clinical Examples for Documentation

CLINICAL DOCUMENTATION The providers need to be specifying the anatomical location and laterality in the documentation to select the appropriate most specific ICD codes.  There are a few examples of clinical documentation updated below and how the physicians and clinicians communicate and what they pay attention to it is a matter of ensuring the information is captured in your documentation. In ICD-10-CM, there are three main categories of changes, Definition Changes Terminology Differences Increased Specificity The expansion of ICD-10 codes is due to the addition of laterality (left, right, bilateral). Physicians and other clinicians likely already note the side when evaluating the clinically pertinent anatomical site(s). Clinical Examples:1 - ACUTE MYOCARDIAL INFARCTION (AMI) When documenting an AMI, include the following, Timeframe An AMI is now considered “acute” for 4 weeks from the time of the incident. The episode of care ICD-10 does not capture an episode of care (e.g. initial,

Clinical Example for Critical Care

Clinical Examples - Critical care services An 85-year-old male patient is admitted to the intensive care unit following abdominal aortic aneurysm resection. Two days after surgery he requires fluids and pressors to maintain adequate perfusion and arterial pressures. He remains ventilator-dependent. A 66-year-old female patient is 4 days status post mitral valve repair. She develops petechiae, hypotension, and hypoxia requiring respiratory and circulatory support. A 72-year-old male admitted for right lower lobe pneumococcal pneumonia with a history of COPD becomes hypoxic and hypotensive 2 days after admission. A 58-year-old admitted for an acute anterior wall myocardial infarction continues to have symptomatic ventricular tachycardia that is marginally responsive to antiarrhythmic therapy Clinical Examples - Non Covered Critical care services The Patients admitted to a critical care unit because no other hospital beds were available. The Patients admitted to a critical care unit for c