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.
At the recent public ICD-10 Coordination and Maintenance Committee Meeting, the Centers for Disease Control and Prevention National Center for Health Statistics discussed a draft proposal involving an expansion of sepsis diagnosis coding. Review the updates being considered for implementation on April 1, 2027. Note : To access this free article, make sure you first register if you do not have a paid subscription.
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.
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.
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.
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.
Q: What steps should medical coders take to correctly code adverse drug effects in ICD-10-CM, and when should a provider query be submitted if documentation is unclear or unspecific?
According to data from the Centers for Disease Control and Prevention, the U.S. recorded 649 maternal deaths in 2024. While the total number of deaths declined slightly from 669 deaths in 2023, the overall maternal mortality rate showed no statistically significant improvement, highlighting ongoing challenges in maternal health outcomes.
Recovery auditors and payers have demonstrated an eagerness to exploit what providers routinely state in the medical record to facilitate additional DRG validation and medical necessity denials. Therefore, knowing what should not be said in a medical record is worth reviewing. To illustrate, Trey La Charité, MD, FACP, SFHM, CCS, CCDS, lists 10 things providers should never be documenting in the medical record.
In December 2023, the Office of the Inspector General published a toolkit for Medicare Advantage organizations who submit high-risk diagnoses, and it announced in January 2026 that an audit will be conducted on high-risk codes that the organizations submitted for 2024. Nancy Reading, BS, CPC, CPC-P, CPC-I, reviews the high-risk codes and emphasizes what to look for in the documentation to support coding practices.
