Q: If our physician only documents “uncontrolled diabetes” in an admitted patient’s chart, but I can see from the lab results in the record that the patient’s blood glucose levels are high, can I go ahead and assign the ICD-10-CM code for diabetes with hyperglycemia?
Q: I’m a registered nurse, and I received treatment at the ER of the hospital where I work. When I asked for a return-to-work note the next day, the physician told me that my supervisor called her the previous evening and asked if I had asked for the note. Is this a HIPAA violation?
Q: The American Medical Association added three new CPT codes for skin biopsies, effective January 1. What are the new biopsy codes and CPT guidelines for reporting them?
