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cpc guidelines
| Question | Answer |
|---|---|
| should signs and symptoms not normally associated with a disease be coded in addition to the diagnosis? | yes |
| if a condition is described as acute and chronic, how should it be coded? | if two distinct codes exist for acute and chronic, code both and sequence acute first |
| a single code that classifies two diagnosis (or a diagnosis with a secondary process or complication) | combination code |
| what is the residual effect after the acute phase of an illness has ended? | sequela |
| when coding sequela, how many codes are needed? | two; the condition of the sequela, then the sequela code. except when a manifestation exists |
| when coding sequela, should the acute phase of an illness that led to the sequela be used? | no |
| when is it acceptable to code signs and symptoms? | when there is no confirmed diagnosis |
| when coding descriptions 'impending' or 'threatened,' what is reported if reported if it did occur? | code as a confirmed diagnosis |
| how many times can each unique diagnosis code be reported per encounter? | once, even when bilateral |
| if no bilateral code exist for a condition, how should it be coded? | assign one code for each side |
| which physician is responsible for documenting bmi, non-pressure, and pressure ulcer stages? | primary care provider |
| when are bmi codes be reported as the first listed? | never |
| when is it appropriate to assign codes for complications of care? | when there is a cause and effect, and an indication that it is a complication |
| when is hiv listed as the principal diagnosis? | only when it is related to the condition the encounter is for |
| when is asymptomatic hiv status used? | when patient does not have documented symptoms and is labeled as hiv positive. if the patient is treated for anything hiv related, do not use Z21 |
| what code is used for patients with inconclusive serology and no definitive diagnosis or manifestations? | B20 |
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