Q: What considerations should coders keep in mind when referring to problem lists for determining the principal diagnosis and proper sequencing of all documented conditions in the inpatient setting?
Trey La Charité, MD, FACP, SFHM, CCS, CCDS, discusses how without some form of a narrative in documentation, hospital coders cannot sequence individual diagnoses. If there is no story provided, records can be rife with opportunity for a recovery auditor or payer to construct an alternative version of what happened during hospital visits, resulting in denials.
Coding purpura and thrombocytopenia is often more straightforward than coders initially expect, as these diagnoses typically require minimal direction from official guidelines. The real challenge lies in correctly interpreting provider documentation and validating the terminology used. Without close attention to clarifying terms, coders risk misclassification or unnecessary queries. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Transcatheter aortic valve replacement is a minimally invasive procedure developed to treat patients with severe aortic stenosis who are considered high-risk or unsuitable candidates for traditional open-heart surgery. Learn from Jane Arbogast-Schappell, CIRCC, CPC, CCS, as she walks through the procedural coding for both inpatient and outpatient settings.
Review a recent OIG audit which found that Medicare improperly paid $22.7 million to suppliers for durable medical equipment, prosthetics, orthotics, and supplies during inpatient stays from January 2018 to December 2024.
Organizations have become increasingly aware that social determinants of health play a major role in determining health disparities. With this in mind, Kelly Rice, MSHI, BSN, RN, CCDS, CDIP, CCS, CRC, reviews the changes to SDOH for FY 2026 and the response to such changes, explores strategies for continued capture of SDOH, and emphasizes the use of new SDOH ICD-10 codes available.
A study published in JAMA found that people who experience a traumatic spinal cord injury are at a greater risk of developing long-term chronic conditions such as hypertension, stroke, heart disease, diabetes, and other neurological and psychiatric conditions.
Failure to rescue is a compelling quality metric because it offers a lens through which healthcare organizations can illuminate, analyze, and improve the rescue zone of patient care. Teresa Brown, RN, CCDS, CCDS-O, CDIP, CCS , shows how this metric can guide meaningful improvement in patient safety and outcomes when coding and CDI professionals help use it thoughtfully.
Laurie L. Prescott RN, MSN, CCDS, CCDS-O, CDIP, CRC, provides a summary of the changes to the SOFA assessments and corresponding scoring now that JAMA Network Open recently published the consensus statement Rational and Methodological Approach Underlying the Development of the Sequential Organ Failure Assessment (SOFA)-2 Score. Note : To access this free article, make sure you first register if you do not have a paid subscription.
