Collaboration can take many forms depending on the needs of an organization, but Leah Ainsworth, BSHIIM, RHIA, CDIP, CCS, CCDS, shows how her department is just one of many to make coding and CDI work hand in hand to create meaningful impacts and ensure accuracy.
CMS announced it is adding 80 new procedure codes to the fiscal year 2026 ICD-10-PCS code set, available for discharges occurring from April 1 through September 30, 2026. This is in addition to the 156 new codes that went into effect on October 1, 2025. Only two codes will be deleted.
Coding for spinal fusions can be very complex, with many different devices and approach options as well as the procedure requiring more than one code. Terry Tropin, MSHAI, RHIA, CCS-P, walks through the New Technology section of the ICD-10-PCS along with other less common sections to find where appropriate spinal fusion codes can be located.
CMS announced its A/B Medicare administrative contractors have withdrawn the local coverage determinations for skin substitute grafts/cellular and tissue-based products for the treatment of diabetic foot ulcers and venous leg ulcers.
Medical coders work with many different code sets including CPT, HCPCS, ICD-10-PCS, and ICD-10-CM. This means coders need to be well-versed in medical terminology. One terminology not often talked about in coding circles is the Systematized Nomenclature of Medicine Clinical Terms—despite the system being around for more than 20 years.
Use the documentation “cross-out test,” clinical vignettes, and expert answers to scenarios to educate staff about when they can and cannot unbundle an evaluation and management visit from a same-day procedure.
Q: A patient was initially treated for extensive burns on his lower back and the posterior side of both thighs. The physician documented that the patient had second- and third-degree burns of the lower back (2% Total Body Surface Area [TBSA] second-degree and 7% TBSA third-degree) and third-degree burns of both thighs (9%). What ICD-10-CM codes would be assigned for this encounter?
Medicare pays for physical and occupational therapy services when the medical record and the information on the claim form accurately report covered therapy services. This article discusses Medicare’s documentation requirements to justify billed therapy services. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
As denials rise, watch for E/M scrutiny with diagnostic X-rays. Billing experts advise that practices should be watchful for these and challenge them when they occur.
With the start of a new year, take a moment to refresh yourself on the ins and outs of the primary code sets an outpatient coder needs to understand and use in their role. This article provides a brief overview of three code sets that will serve as a review for veteran coders or a solid base of information for new coders.
