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.
Just as healthcare continues to evolve and change, a successful CDI program must also evolve and change. The work of the CDI team creates a positive impact in several crucial areas, including documentation accuracy and completeness, patient safety, revenue cycle, and regulatory compliance. CDI specialists play a vital role in ensuring that medical records are accurate, complete, and a reflection of the true clinical picture, which is crucial for patient safety and accurate billing.
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.
Our experts answer questions about the 2026 Medicare Physician Fee Schedule final rule, coding an excision of a ganglion cyst, and coding first-degree burns.
Our experts answer questions on sorting through problem lists for the principal diagnosis, coding poisonings with resulting manifestations, and capturing loss of consciousness status.
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.
Accurate provider documentation is the foundation of compliant coding, appropriate reimbursement, and defensible claims. Yet, in a rapidly changing healthcare landscape, even highly skilled clinicians can find it difficult to stay current.
Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I, shows how reporting perinatology procedures with ICD-10-PCS is essential to accurately reflect the complexity, effectiveness, and clinical value of life-altering interventions that correct some congenital anomalies, ensuring they are visible in clinical data, recognized by payers, and supported for continued access and advancement in fetal care.
Social determinants of health (SDOH) are critical for the well-being of the patient and are often more important than what occurs in physician’s offices, laboratories, operating rooms, and other clinical settings. Accurately capturing SDOH and providing education on doing so are equally critical for patient care, quality reporting, and reimbursement.
Clinics, specialty groups, and ambulatory care centers are facing systemic strains from the outpatient healthcare infrastructure, according to the Outpatient Pressure Index 2025 published by CERTIFY Health.
