The Outpatient Code Editor (OCE) provides the answers to the test, but to use it effectively, you need to understand the history and the complex configuration of all the parts.
The pelvis encloses and supports the internal organs, so a pelvic ring fracture—commonly caused by traumatic events such as car crashes—can trigger extensive internal bleeding and other injuries. Learn about some CPT fracture codes for posterior pelvic ring fractures that would be reported in many trauma situations.
Our experts answer questions about diabetes mellitus in remission, percutaneous versus endoscopic discectomies, and complicated and uncomplicated problems.
While many bone fractures are often treated in emergency rooms or orthopedic clinics, certain fractures—especially severe, complex, or high-risk ones—tend to require inpatient admission. Nancy Reading, BS, CPC, CPC-P, CPC-I , shows how recognizing severity of fractures that may warrant hospitalization helps coders capture the full scope of the patient’s condition.
Our experts answer questions on better coding and CDI collaboration for escalation processes and AI implementation, queries for undocumented diagnoses and cause-and-effect relationships, and codes for hemorrhages as surgical complications.
With takeaways from three certified medical professionals, HIM professionals can discover how the complexity of care for major depressive disorder impacts decisions around admissions, treatment intensities, resource allocations, and service quality, beginning with outpatient care.
Because anemia is not a definitive diagnosis due to the condition having many possible causes and just as many clinical presentations, Nancy Reading, BS, CPC, CPC-P, CPC-I , visits several of the common etiologies for anemia as well as associated coding concerns.
CMS recently released an updated MLN fact sheet reminding providers when implantable pulmonary artery pressure sensors for heart failure can be covered under the coverage with evidence development policy. Included are the ICD-10-CM/PCS codes that must be reported for inpatient cases.
Q: When a diagnosis is clinically evident but not yet documented or there is uncertainty about a cause-and-effect relationship between related conditions, would queries be outlined similarly to other types of queries or include different information?
Cirrhosis of the liver is categorized into distinct types that reflect different patterns of liver injury and disease progression, including hepatic fibrosis and hepatic sclerosis. Proper identification of these forms is critical for clinical accuracy and coding compliance.
