Avoiding claims denials requires compliance with coding guidelines.  In CPT, a common area of noncompliance is the documentation and coding of injections and infusions.  The Emergency Room is one service area wherein injections and infusions are common treatments for a multitude of diagnoses.  

When coding malignant neoplasms, there are several coding guidelines we must follow: 
To properly code a malignant neoplasm, the coder must first determine from the documentation if the neoplasm is a primary malignancy or a metastatic (secondary) malignancy stemming from a primary cancer.

Encounters for patients who are pregnant, in delivery, or in the puerperium, use codes from Chapter 15 Pregnancy, Childbirth and the Puerperium (O00-O9A).  There are key data points and specific guidelines that must be followed.  As with all coding, remember to imagine how the story unfolded and aim to relay that story with the correct codes. A well-documented provider’s note related to the care of an antepartum or postpartum patient will include...