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.
Take three steps when an assistant surgeon helps during a procedure. First, make sure an assistant-at-surgery modifier is appropriate for the procedure. Second, make sure the primary surgeon’s note explains why they needed the help of a qualified healthcare professional (QHP) or another physician for the procedure. Third, make sure you select the correct modifier, based on the assistant’s credentials and role.
Our experts answer questions about the multiple sclerosis medication administration, coding a crack cocaine overdose, and Medicare administrative contractors.
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.
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.
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.
A neonatal intensive care unit offers very specialized medical services and treatments to premature and critically ill neonates (i.e., babies 28 days old or younger). Review which ICD-10-CM and CPT codes may be used for providers assisting in this type of care.
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.
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.
