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Coding Tips
Welcome to UASI's Coding Corner! We're here to make your medical coding journey smoother and more enjoyable with our friendly and practical tips. Whether you're just starting out or you've been in the field for years, you'll find something useful here. Our expert advice, handy tricks, and up-to-date industry insights are all geared towards helping you code more accurately and efficiently. So, grab a cup of coffee, get comfy, and explore our tips to take your coding skills to the next level!
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Many coders still struggle with assigning the seventh character for initial and subsequent encounters. Using these correctly ensures accurate reimbursement and avoids claim denials. When assigning the 7th character for injuries or conditions like fractures, sprains, or open wounds, do not confuse “initial” with the patient’s first visit. Initial Encounter (A) = Active treatment is still being provided – “surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician.” Subsequent Encounter (D) = The patient is in the healing or recovery phase, receiving routine follow-up care - “cast change or removal, an X-ray to check healing status of fracture, removal of an external or internal fixation device, medication adjustment, and other aftercare and follow-up visits following treatment of the injury or condition.” In ICD-10-CM, “initial” vs. “subsequent” is about the type of care being provided, not the location (like inpatient vs. outpatient) Use 7th character “A” (Initial Encounter) when the patient is receiving active treatment for the injury – regardless of whether they’re in the ER, surgery, or admitted inpatient. Use 7th character “D” (Subsequent Encounter) once the patient is receiving routine aftercare for healing – even if they are still in the hospital (e.g., rehab or post-op management).
Optilume is an FDA approved drug-coated balloon, developed by Urotronic, that is inserted via cystoscopy to dilate and treat urethral strictures or stenosis caused by benign prostatic hyperplasia (BPH). It is a minimally invasive procedure that provides immediate relief from the urinary symptoms men can experience with BPH. A CPT code, 52284, was introduced in 2024 which can be used when a cystoscopy with Optilume is performed. The drug on the outer surface of this balloon (paclitaxel), once absorbed, may help maintain the stricture expansion and help improve urinary flow. The balloon is not left inside the patient, but rather taken out after 5 minutes of inflation, leaving the drug to do its job with the rest. Key Points for Coders Use CPT 52284 only when a drug-coated balloon (like Optilume) is used during cystoscopy to treat urethral stricture/stenosis. Documentation must clearly state: Use of Optilume Paclitaxel drug delivery Balloon inflation and removal Do not code separately for the drug Use C1889 for the device code Ensure the diagnosis supports stricture/stenosis, not just BPH. This code is new in 2024—don’t use it for earlier dates. Watch for bundling and use modifiers only if appropriate. Check payer policies for coverage and authorization requirements References: Optilume BPH Catheter System – P220029 | FDA Optilume Optilume® for Urethral Stricture | Urethral Drug Coated Balloon CPT Assistant, February 2024, Volume 34, Issue 2, page 21 Coders Desk Reference
By now, you’ve all seen and coded a leadless pacemaker. Did you know they make dual-chamber leadless pacemakers?
Myocarditis is a condition where the heart muscle becomes inflamed. It is most commonly caused by an infection in the body, such as a viral infection (including those that cause the common cold, influenza or COVID-19), bacterial infection (such as diphtheria or strep), or fungal infection (such as candidiasis). In severe cases, myocarditis may lead to stroke, heart attack, heart failure or death.
Under CPT guidelines, an office visit may be billable when a family member or caregiver attends in place of the patient, as long as the patient is already established and documentation requirements are met. Per 2025 E/M guidelines, time-based coding can apply to visits involving the physician and/or family/caregiver, not just the patient. Further instructions state that it includes both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician on the day of the encounter. Additional tips and guidance: Confirm Patient Status First: Before billing, verify that the patient is already established in your practice. New patient visits cannot be billed if the patient is not present, even if a family member or caregiver is. Thoroughly Document : Ensure documentation clearly identifies that the patient was not present, the reason for their absence, the medical necessity of the visit, the topics discussed with the caregiver/family member, time spent (if using time-based coding) Use Appropriate E/M Code Level : When time-based coding is used, make sure the total time spent on the date of service is documented, including time spent with family/caregiver and r elevant non-face-to-face activities, such as reviewing records, documenting in the EHR, or ordering tests Check for Payer-Specific Limits : Some payers may not allow billing if the patient is not physically present, even if CPT supports it. Medicare, for instance, has historically had stricter interpretations. Always verify policy-specific rules. Reference: CPT Assistant, March 2013, Vol 23, Issue 3, page 13 Note: Always review payer-specific guidance, as interpretations may differ from AMA recommendations
Hemorrhagic Stroke: About 13 percent of strokes happen when a blood vessel ruptures in or near the brain. This is called a hemorrhagic stroke. When a hemorrhagic stroke happens, blood collects in the brain tissue. This is toxic for the brain tissue, causing the cells in that area to weaken and die. Are all hemorrhagic strokes the same? There are two kinds of hemorrhagic stroke. In both, a blood vessel ruptures, disrupting blood flow to part of the brain . Intracerebral hemorrhages (most common type of hemorrhagic stroke): they occur when a blood vessel bleeds or ruptures into the tissue deep within the brain. They are most often caused by chronically high blood pressure or aging blood vessels. Subarachnoid hemorrhages : Occur when an aneurysm (a blood-filled pouch that balloons out from an artery) on or near the surface of the brain ruptures and bleeds into the space between the brain and the skull. Ischemic Stroke : The majority of strokes (87%) occur when blood vessels to the brain become narrowed or clogged with fatty deposits called plaque. This cuts off blood flow to brain cells. A stroke caused by lack of blood reaching part of the brain is called an ischemic stroke. High blood pressure is a leading risk factor for ischemic stroke An ischemic stroke occurs when a clot or a mass blocks a blood vessel, cutting off blood flow to a part of the brain. There two main types of ischemic stroke. Cerebral thrombosis is caused by a blood clot (thrombus) in an artery going to the brain. The clot blocks blood flow to part of the brain. Blood clots usually form in arteries damaged by plaque. Cerebral embolism is caused by a wandering clot (embolus) that’s formed elsewhere (usually in the heart or neck arteries). Clots are carried in the bloodstream and block a blood vessel in or leading to the brain. A main cause of embolism is an irregular heartbeat called atrial fibrillation. Also code : Report all neurological deficits that occur during the hospitalization, even if they resolve before discharge. Please pay special attention to laterality . When reading the chart, please try to find specificity regarding whether the deficit affects the dominant or non-dominant side of the body. Also code: NIHSS Scores : The NIHSS is a neurological exam that is scored on all acute stoke patients. The score describes the severity of the stroke from no stroke (score of zero) to severe stroke (score of 21-24). - info from Coding clinic 4th Q 2016 p.61 *information obtained from the American Stroke Association
H ow to code a hepatic thrombus that extends into the atrium.
Prevalence & New ICD-10-CM Code Updates Childhood obesity remains a pressing public health concern in the United States. According to the CDC, approximately 1 in 5 children and adolescents — about 19.7% of those aged 2–19 years—are affected. That’s an estimated 14.7 million young people across the country. Obesity Trends Among U.S. Youth Childhood obesity isn’t distributed evenly. Rates vary across age groups , racial/ethnic backgrounds , and socioeconomic status : By Age Ages 2–5: 12.7% Ages 6–11: Data not specified in this summary Ages 12–19: 22.2% By Race & Ethnicity Hispanic: 26.2% (highest prevalence) Non-Hispanic Black: 24.8% Non-Hispanic White: 16.6% Non-Hispanic Asian: 9.0% By Family Income Children in households at or below 130% of the Federal Poverty Level (FPL) have a 25.8% obesity rate—highlighting a clear socioeconomic link. New ICD-10-CM Codes for Pediatric Obesity – Effective October 1, 2024 To support more accurate diagnosis and classification, the FY 2025 ICD-10-CM updates introduced new and revised codes for pediatric obesity and BMI. New Obesity Classification Codes These now distinguish between three classes of obesity , based on BMI: E66.811 – Obesity, Class 1 (BMI: 30–34.9) E66.812 – Obesity, Class 2 (BMI: 35–39.9) E66.813 – Obesity, Class 3 (BMI: ≥40) Pediatric BMI Code Updates BMI coding for youth aged 2–19 years is now more detailed, enabling better tracking and clinical alignment with growth charts. Z68.54 – REVISED: Pediatric BMI at 95th percentile to <120% of the 95th percentile Z68.55 – NEW: Pediatric BMI at 120% to <140% of the 95th percentile Z68.56 – NEW: Pediatric BMI at ≥140% of the 95th percentile Reminder : Pediatric BMI codes apply to ages 2–19 . Adult BMI codes are for patients 20+ years . Why These Code Changes Matter The updated codes aim to: Improve diagnostic accuracy for healthcare providers. Align more closely with current pediatric obesity guidelines . Support better data tracking and research . Help identify patients at higher risk for comorbidities linked to severe obesity. Final Thoughts These coding updates aren’t just bureaucratic changes—they’re designed to enhance the way we identify, track, and treat obesity in young patients. Accurate coding leads to more personalized care, better public health interventions, and stronger advocacy for at-risk children. Sources: Childhood Obesity Facts | CDC ICD-10-CM Guidelines FY25, October 1, 2024 New Childhood Obesity ICD-10-CM Codes – Partner Promotion Materials
New COVID-19 Coding Guidelines
A recent question to the AHA Coding Clinic asked whether Parkinson’s Disease (PD) with tremor could be coded as Parkinson’s Disease with dyskinesia . The official guidance was clear: “Codes in subcategory G20.B- , Parkinson’s disease with dyskinesia, should only be assigned when dyskinesia associated with Parkinson’s disease is specifically documented by the provider. ” New ICD-10-CM Codes Effective October 1, 2023: G20.A1 – Parkinson’s disease without dyskinesia, without mention of fluctuations G20.A2 – Parkinson’s disease without dyskinesia, with fluctuations G20.B1 – Parkinson’s disease with dyskinesia, without mention of fluctuations G20.B2 – Parkinson’s disease with dyskinesia, with fluctuations G20.C – Parkinsonism, unspecified Tremor vs. Dyskinesia in Parkinson’s Disease Both tremor and dyskinesia are movement disorders associated with PD, but they differ significantly in cause, presentation, and treatment. Here's a breakdown: 1. Tremor in Parkinson’s Disease Definition: Involuntary, rhythmic, oscillatory movement of a body part Typical Type in PD: Resting tremor — appears when the body part is at rest and improves with movement Characteristics: Frequency: 4–6 Hz Location: Commonly begins in one hand (e.g., “pill-rolling” tremor between thumb and fingers) Asymmetry: Often starts on one side of the body Triggers: Worse at rest, improves with movement or posture Cause: Dopamine depletion in the basal ganglia Treatment: Dopaminergic medications (e.g., Levodopa) Deep Brain Stimulation (DBS) in advanced cases 2. Dyskinesia in Parkinson’s Disease Definition: Abnormal, involuntary movements that are fluid, dance-like, or jerky Type in PD: Levodopa-induced dyskinesia (LID) — occurs as a side effect of long-term levodopa therapy Characteristics: Timing: Occurs at peak dopamine levels or during medication transitions Appearance: Chorea (random jerky movements), dystonia (sustained contractions), or both Location: May involve limbs, trunk, or face Triggers: High-dose or long-term levodopa use Cause: Pulsatile dopamine stimulation causes maladaptive changes in the basal ganglia Treatment: Adjusting levodopa (e.g., smaller, more frequent doses) Adding adjunct therapies (amantadine, dopamine agonists) Advanced options: DBS or continuous infusion (e.g., Duodopa) Key Differences Between Tremor and Dyskinesia Nature: Tremor: Rhythmic and oscillatory Dyskinesia: Irregular, flowing, or jerky Timing: Tremor: Worse at rest, better with movement Dyskinesia: Tied to medication timing (often peak-dose) Cause: Tremor: Dopamine deficiency Dyskinesia: Long-term use of levodopa Treatment Focus: Tremor: Dopamine replacement Dyskinesia: Medication adjustment or adjuncts Clinical Pearls Tremor is a core symptom of Parkinson’s and may be present at diagnosis. Dyskinesia is typically a treatment-related complication , appearing after years of therapy. Proper distinction between tremor and dyskinesia is essential for correct coding and treatment planning. Additional Clarification from Coding Clinic (Q4 2023) “Parkinson’s disease is a progressive neurodegenerative condition presenting with motor symptoms (e.g., tremors of hands, arms, legs, or head) and non-motor symptoms (e.g., depression, anxiety, pain). Dyskinesia is defined as involuntary movements of the face, arms, legs, or trunk. Fluctuations refer to alternating ON episodes (positive response to levodopa) and OFF episodes (return of symptoms as medication wears off).”
