TOP ICD-10-CM CODES (memorise these):
E11.9 Type 2 DM, no complications
E11.65 Type 2 DM with hyperglycemia
I10 Essential (primary) hypertension
I50.9 Heart failure, unspecified
I50.23 Acute-on-chronic systolic CHF
J18.9 Pneumonia, unspecified organism
J44.1 COPD with acute exacerbation
N18.3 CKD stage 3
M79.3 Panniculitis (unspecified)
Z00.00 Encounter for general adult medical exam
Z12.11 Encounter for screening for malignant neoplasm of colon
Z79.4 Long-term (current) use of insulin
Z87.891 Personal history of nicotine dependence
TOP CPT E&M CODES:
99213 Office/outpatient established, low complexity
99214 Office/outpatient established, moderate complexity
99215 Office/outpatient established, high complexity
99203 Office/outpatient new, low complexity
99204 Office/outpatient new, moderate complexity
99232 Hospital subsequent, moderate complexity
99283 Emergency dept, moderate complexity
99291 Critical care, first 30-74 minutes
TOP MODIFIERS:
-22 Increased procedural services
-25 Significant, separate E&M same day as procedure
-26 Professional component only
-50 Bilateral procedure
-51 Multiple procedures
-59 Distinct procedural service
-76 Repeat procedure same physician
-TC Technical component only
-LT/-RT Left/Right side
CODE SEQUENCING:
Inpatient: principal diagnosis first (condition after study that occasioned admission)
Outpatient: first-listed diagnosis (condition chiefly responsible for the visit)
CODE TO HIGHEST SPECIFICITY:
Wrong: E11.9 (unspecified) when documentation says "with neuropathy"
Right: E11.40 (Type 2 DM with diabetic neuropathy, unspecified)
UNCERTAIN DIAGNOSES:
Inpatient: code probable/suspected/likely as confirmed
Outpatient: code symptoms only (NOT probable/suspected/rule out)
COMBINATION CODES:
Use single combination code when available (E11.65 = DM2 + hyperglycemia)
Do not code two codes if one combination code covers both conditions
SIGNS AND SYMPTOMS:
Code as additional: if not routinely associated with confirmed diagnosis
Do NOT code: if integral to confirmed diagnosis (cough with COPD = don't separately code)