When the injury is treated with Steri-Strips or bandages, it should be reported with an E/M code and not a procedure code. Within the medical decision making, the number and complexity of problems addressed is low, the amount of data reviewed or analyzed is straightforward, and the risk of complications and/or morbidity or mortality of patient management from the injuries is low.
Therefore, the E/M is a 99213 because the medical decision-making is low. A suicide attempt would not be coded because the documentation is not specific as to whether the lacerations were an attempt at suicide.

In this case, the patient is not at risk, and most organs either are not developed and/or cannot be visualized in the first trimester. Thus, this would constitute as waste due to the provider overutilizing services that result in unnecessary cost. AAPC defines fraud as purposely billing "for services that were never given or to bill for a service that has a higher reimbursement than the service provided." Abuse is payment for services "that are billed by mistake by providers."

When splitting/providing relief in the middle of a procedure, the anesthesiologist who provides services for the longest amount of time bills for the anesthesia services in their entirety. In this scenario, Anesthesiologist Z provided 60 minutes more than Anesthesiologist A and so would bill for the entire 4.5 hours. Even though Anesthesiologist A provided 1.75 hours, they would not submit any coding to the insurance carrier.

The diagnosis is always based on the provider's documentation, which in this case would be obesity. Coding guidelines also state that if there is a reportable diagnosis related to weight, "the BMI can be assigned from documentation of someone other than the patient's provider, such as nursing notes."

When a hematologr procedure that could be billed alone is encompassed in another code, only the most complex of the tvo should be reported. Because CPT 85046 includes the reticulocyte count billing CPT 85044 as secondary despite using a different method would be considered an unbundling of services. Per ICD-IO-CM guidelines, an organ or tissue transplant status code is for use "only if there are no complications or malfunctions of the organ or tissue replaced." As the testing is to determine whether the engraftment was successful, a bone marrow transplant status code would not be appropriate until deemed by the provider.