Reducing hospital readmissions has long been a health policy goal, and CDI programs have started to track and review this metric for improvement. Learn how CDI teams are addressing readmissions, as a familiarity with risk adjustment and the impact of documentation can prove useful to coders who also play a role in risk adjustment through their translations of complete documentation into precise codes.
One of the most frequent causes of hospital-acquired AKI is acute tubular necrosis (ATN). Improving documentation and coding practices for ATN involves not only recognizing the condition but also realizing the impact of coding ATN versus AKI, addressing common misconceptions in the HIM field, and fostering collaboration among CDI specialists, coding professionals, and providers.
Our experts answer questions on overcoming documentation challenges for sepsis, ICD-10-CM coding for infections of devices vs. wound infections as well as class three obesity and/or morbid obesity, and querying physician abbreviations.
With 50 new ICD-10-PCS codes implemented on April 1, Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , thoroughly reviews the codes to help inpatient coders accurately apply the updates.
The spectrum of myocardial injury, ischemia, and infarction represents a critical area in cardiology, which Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , explores in detail, integrating information from current clinical guidelines, diagnostic standards, and management strategies.
There were 371 new codes added to the October update of the 2025 ICD-10-PCS code set, but Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , narrows her investigation into the new codes for one particular body system within the Medical and Surgical section: Lower Arteries.
Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS , and Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, CCDS-O , review some of the significant changes to the first quarter of AHA’s 2025 Coding Clinic.
For fiscal year 2025, ICD-10-CM Chapter 19 saw an addition of 18 new codes for poisoning by, adverse effect of, and underdosing of immune checkpoint inhibitors and immunostimulant drugs. To properly apply these new codes, Nancy Reading, RN, BS, CPC, CPC-P, CPC-I , breaks down the purposes of these medications and explains how the coding guidelines address the complex range of side effects these drugs can cause.
Given the variety and complexity of surgical complications, coders should understand the nuances of differentiating between surgical complications and pre-existing conditions, stay up to date with coding guidelines, and familiarize themselves with ICD-10-CM chapters where complications codes are located.
