Q: What clinical factors distinguish acute skin failure from a pressure injury, and how should the two conditions be approached from an ICD-10-CM coding perspective?
A TIA is typically a short-lived transient event that results in no permanent tissue damage or residual neurologic deficits. On the other hand, a stroke results from either a vessel blockage or a hemorrhage, causes some variety of tissue damage, and may leave residual neurologic deficits. Follow Nancy Reading, BS, CPC, CPC-P, CPC-I, as she explores the differences between these two conditions.
Identifying secondary diagnoses is an important part of accurately reflecting the patient’s overall condition and the care provided during an encounter. While the primary diagnosis represents the main reason for the patient’s visit or admission, secondary diagnoses capture additional conditions that require attention or have an impact on the patient’s care. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Society is working hard to eliminate or reduce the stigma associated with the need for psychological healthcare services. Some patients require more intensive treatment and focused care, and the services provided during these inpatient stays are reported using codes from ICD-10-PCS, specifically those found in Section G. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, provides an in-depth review of this section and the many services that can be reported.
A report issued by the Centers for Disease Control and Prevention found that 15.2% of U.S. pregnant women reported current alcohol consumption during the past 30 days. The report, which examined 2021–2024 data from the Behavioral Risk Factor Surveillance System, also found that 4.9% of pregnant women reported binge drinking and 2.2% reported heavy drinking.
Congenital heart defects are commonly encountered chronic conditions in pediatric coding and documentation, yet their presence alone does not ensure they are appropriately reported or fully understood within the clinical context of an encounter. Jenny Esper, RHIA, CCS, CDIP, CCDS, tackles the challenges of determining when a CHD is relevant to the admission and whether the documentation accurately reflects its clinical significance for proper coding.
The prevalence of healthcare-associated infections in U.S. hospitals declined between 2015 and 2023, according to a Centers for Disease Control and Prevention survey published recently in The New England Journal of Medicine . The findings show continued progress in reducing infections acquired during hospital care, although researchers noted that the overall burden of HAIs persist.
The ICD-10-PCS updates for fiscal year 2027 were released in June, and its new codes will be effective Oct. 1, 2026. A majority of the modifications involve new qualifier values for generic devices, but in some cases, new values were added to report brand-named devices. Terry Tropin, MSHAI, RHIA, CCS-P, focuses on the changes to the New Technology section.
Understanding the clinical findings associated with quadriplegia is an important first step in determining how the condition should be reported. After reviewing the causes and effects of quadriplegia and reportable ICD-10-CM codes for the condition, this article will dive into key physical examination findings and documentation considerations that can help further guide accurate code selection. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Q: What are the key characteristics of cachexia versus ASPEN-defined malnutrition, and what ICD-10-CM codes are available for reporting each condition?
