From concussions and cerebral contusions to complex intracranial hemorrhages and traumatic brain injuries, major head injuries encompass a wide spectrum of clinical presentations and outcomes. Because of their complexity and potential for lasting impact, complete and compliant ICD-10-CM coding is essential to reflect the full clinical severity of these conditions. Note : To access this free article, make sure you first register if you do not have a paid subscription.
A prognostic study published in the Journal of the American Medical Association raises concerns that AI models designed to predict hospital outcomes may appear far more accurate than they truly are due to a subtle but serious methodological error known as label leakage.
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.
Q: How do ICD-10-CM T codes work together with Z, F, and Y codes to fully capture drug-related conditions, and in what order should these codes be sequenced?
Addressing the reliability of documentation, coding, and clinical reasoning underlying PSI flags is not simply a clinical safety imperative; it is a strategic business imperative. Priscilla Marlar, MHA, CSSBB, CPHQ, and John W. Cromwell, MD, suggest that achieving high reliability in quality data integrity starts with understanding the nuances of clinical documentation language and how those nuances are translated by CDI and coding teams into hospital billing codes.
