Is the ICD-10-CM code enough?

Question:

I am reaching out to ask if a provider lists the ICD-10-CM code with code description on the encounter under the Assessment and Plan if this is sufficient to use as their documentation and would this pass in an audit?

I do not believe this meets the ICD-10-CM guidelines and would like some clarification that I'm not querying erroneously.

Thank you in advance for your response to this matter!

Answer:

Thank you for your query, it is a great question.

No, it is not sufficient for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement. The AHA coding clinic, specifically the 4th quarter of 2015, states that the ICD-10 codes are "statistical classifications, not replacements for a provider's written diagnosis."

*This response is based on the best information available as of 01/08/26.

Documenting Occlusions for 2026 Lower Extremity Endovascular Revascularization Coding

Question:

The CPT guidelines for the lower extremity endovascular revascularization codes state that a straightforward lesion is a stenosis and a complex lesion is an occlusion. When documenting treatment of an occlusion, must the operative report specify the degree of blockage (for example, 100% or total), or does documentation of the lesion as an occlusion alone support reporting a complex lesion?

Answer:

Documentation of the lesion as an occlusion alone is sufficient to support reporting treatment of a complex lesion. CPT defines lesion complexity by lesion type, not by a percentage of narrowing, and an occlusion by definition represents complete blockage. CPT does not require documentation of “100%” or “total” for code selection. That said, because these codes are newly implemented, providers and coders should continue to monitor local MAC and commercial payer policies for any additional documentation requirements as payers begin to adjudicate claims.

*This response is based on the best information available as of 01/08/26.

ICD-10 – Scar Contracture

Question:

Which ICD-10-CM diagnosis code should be reported for a patient undergoing release of a scar contracture on the flexor surface of the left elbow following healing from a third-degree burn?

Answer:

The scar contracture represents a sequela of the burn. According to ICD-10-CM guidelines, two codes should be reported:

1. L90.5 – Scar conditions and fibrosis of skin

2. T22.322S – Burn of third degree of left elbow, sequela

Key Points:

• ICD-10-CM guidelines instruct reporting the condition or nature of the sequela first, followed by the sequela code.

• Referenced guidelines: I.B.10 and I.C.19.d.7

In summary, reviewing ICD-10 guidelines ensures accurate coding and helps avoid common errors. These guidelines are a crucial resource for accurate code assignment.

Thank you for reaching out to KZA regarding your inquiry.

*This response is based on the best information available as of 01/08/26.

Anterior Approach Spine Fracture

Question:

Good day, my surgeon did a fracture treatment from the anterior approach on the C6-C7 spine; however, he did not do a corpectomy. Should I use the corpectomy code with a 52 modifier or an unlisted code? I was thinking of the comparable code as 22319. Thank you.

Answer:

In spine coding, there are no anterior fracture repair codes outside of the repair of an odontoid fracture. Typically, anterior fracture treatment is reported using existing anterior approach codes, such as anterior cervical discectomy and fusion (ACDF) or corpectomy, depending on the extent of the procedure.

Based on the information provided, it’s unclear precisely what was performed during the surgery, aside from the fact that a corpectomy was not done. Without access to the operative report or more detailed documentation, it’s challenging to make a definitive coding recommendation.

That said, here’s some general guidance: if the vertebral body bone is removed but does not meet the threshold for a corpectomy (which requires removal of at least 50% of the vertebral body for cervical), the procedure would typically be reported as an ACDF. Reviewing the operative note closely or consulting with the surgeon may help clarify whether the procedure aligns more closely with ACDF or warrants the use of an alternative code.

Thank you for reaching out to KZA with your inquiry.

*This response is based on the best information available as of 01/08/26.

Modifier for Postoperative Endoscopic Sinus Debridement

Question:

If one of our physicians performs a septoplasty and sinus surgery and then the patient comes in the office for a 31237 (endoscopic sinus debridement), would we use a modifier 79 (unrelated procedure in a global period) or 58 (staged/anticipated procedure in a global)?

Answer:

The debridement should be considered unrelated to the septoplasty because septoplasty does not routinely require postoperative debridement. Therefore, modifier 79 should be appended to 31237 when the service occurs within the septoplasty’s global period.

Ensure that diagnosis codes are properly linked to the indication for the sinus surgery and the 31237. If 31237 is linked to the septoplasty diagnosis, the payer system will interpret the procedure as related to a 90-day global and may cause a denial.

*This response is based on the best information available as of 01/08/26.

Diastasis Recti Repair

Question:

What is the recommendation for coding an open Diastasis Recti repair, when it is the only procedure performed?

Answer:

There is no specific CPT code for open repair of a Diastasis Recti. If it is the only procedure performed, it is reported with an unlisted code, 49999 or 22999. If it is performed at the same session as an abdominal hernia repair, it is considered part of the reconstruction of the hernia repair and is not separately reported.

*This response is based on the best information available as of 01/08/26.