Immunoglobulin G4-related disease is a chronic immune-mediated fibroinflammatory disorder that often manifests with tumor-like masses and/or painless enlargement of multiple organs. Shontia Leon-Guerrero, CPC, CEDC, CEMC, CPC-I Educator, explores the general manifestations of the disease, its signs and symptoms, as well as key documentation tips and a coding scenario.
Our experts answer questions on clinical recognition of pediatric malnutrition, query opportunities for unclear drug documentation, and clinical validation of tumor lysis syndrome.
Due to all of the possible scenarios that come with a pregnancy, the reporting of ICD-10-CM diagnosis codes must reveal the specific risks patients have so that procedures, services, and treatments can all be supported. Follow Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I, as she outlines best practices for specifically reporting high-risk pregnancies.
A diagnosis of cancer becomes a pre-existing condition that will follow a patient for the rest of their life, but clinical records do not always provide the level of detail required to work within the framework set forward in the coding rules when it comes to reporting active neoplasms from personal history. Nancy Reading, BS, CPC, CPC-P, CPC-I, explores ICD-10-CM guidelines for such neoplasm scenarios.
Our experts answer questions on reporting postpartum hemorrhage; combining ICD-10-CM T codes for drug-related manifestations with Z, F, Y codes; and coding hypoxic-ischemic encephalopathy.
Admit type continues to present a significant risk across hospital operations, driven by limited formal education and widespread misinterpretation of national standards. Penny Jefferson, MSN, RN, CCDS, CCDS-O, CCS, CDIP, CRC, CHDA, CRCR, CPHQ, ACPA-C, explains what admit type actually represents and how it directly influences quality outcomes, reimbursement, and organizational credibility.
Coding for spinal fusions can be very complex, with many different devices and approach options as well as the procedure requiring more than one code. Terry Tropin, MSHAI, RHIA, CCS-P, walks through the New Technology section of the ICD-10-PCS along with other less common sections to find where appropriate spinal fusion codes can be located.
Just as healthcare continues to evolve and change, a successful CDI program must also evolve and change. The work of the CDI team creates a positive impact in several crucial areas, including documentation accuracy and completeness, patient safety, revenue cycle, and regulatory compliance. CDI specialists play a vital role in ensuring that medical records are accurate, complete, and a reflection of the true clinical picture, which is crucial for patient safety and accurate billing.
Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I, shows how reporting perinatology procedures with ICD-10-PCS is essential to accurately reflect the complexity, effectiveness, and clinical value of life-altering interventions that correct some congenital anomalies, ensuring they are visible in clinical data, recognized by payers, and supported for continued access and advancement in fetal care.
Our experts answer questions on sorting through problem lists for the principal diagnosis, coding poisonings with resulting manifestations, and capturing loss of consciousness status.
