Q: A patient with dementia has not taken prescribed Lasix for one week due to forgetting and presents with worsening acute heart failure. What is going to be sequenced first: the underdose or the acute heart failure?
For the 10 years we have been working with the ICD-10-PCS code set, these codes, used to report procedures provided to an inpatient, have required seven characters. Each character reports a very specific element of the service provided. Here, Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, is going to focus on character 6 for Device.
Given the rising relevance of encephalopathy, getting a refresher on what the condition is and why it’s relevant to coding and CDI can benefit all professionals no matter their experience level. And because the clinical validation of encephalopathy is not contingent on a lab finding, but a long chain of events that require each link to be well established, organizations are still finding new ways to leverage innovative tactics in order to document it accurately.
A greater telemedicine uptake among mental health specialists did not result in improved access to care for patients in communities with specialist shortages, according to a study published in JAMA Open Network.
Q: What are some tips for properly documenting evaluation and management as it relates to medical decision-making, including improving communication with providers?
Radiation oncology is a specialty utilizing radioelements either externally or internally to treat medical conditions such as cancer. This article serves as a primer for coding radiation oncology services.
In the current healthcare climate, the issue of medical necessity documentation, or lack thereof, is one of the most common reasons for claim denials. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
ICD-10-PCS coding for procedures performed within the cranial cavity is complicated. Terry Tropin, MSHAI, RHIA, CCS-P, describes the different body part values used for the brain and cranial cavity, root operations used, and coding for some common procedures.
Our experts answer questions on ICD-10-CM coding for adverse effects of medications, ICD-10-PCS coding for stroke intervention procedures, and coding lactic acidosis and sepsis together.
Train your staff on the first batch of medically unlikely edits for CPT codes that went into effect January 1, 2026, along with new edits that just went into effect on April 1.
