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.
Next year’s CPT manual will include new surgical implants to address knee pain and heart failure, repair diaphragm hernias, and excise pharyngeal neoplasms.
Q: When coding endoscopic procedures, some CPT codes have multiple procedures bundled in a single code. How do coders report when one of the procedures isn’t done?
Less than one-half of adults discharged from emergency departments for diabetes-related encounters obtain outpatient follow-up care within 30 days, according to a recent study published in the Journal of General Internal Medicine.
The fiscal year 2027 update to the ICD-10-CM code set includes new, deleted, and revised codes, as well as hundreds of changes to “Excludes” notes and “Code Also” indications. This code set was produced to show greater coding specificity by publishing codes with greater clinical specificity.
Prior to the 1970s, there was not an objective method of evaluation and management documentation, which led to physicians making unscientific decisions about patient treatment. Now, one of the general ways that providers document their services is the SOAP format, which helps them organize their thoughts for a patient encounter. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
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.
Beginning in 2027, services for antepartum care, labor management, delivery, and postpartum care will be coded separately. The old global approach to billing obstetric care was intended to simplify billing, but it no longer reflects the variation and complexity of care across the phases of pregnancy.
Building a strong relationship between coding and CDI begins with the training and education of new professionals. Learn how organizations are using shared education, coding resources, concurrent coding, and ongoing collaboration to close knowledge gaps and help coding and CDI teams resolve DRG mismatches, navigate complex coding questions, and improve documentation and coding accuracy.
