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.
Q: What are the most common reasons postpartum hemorrhage is documented and coded inconsistently, and how can coders and clinicians help address these issues?
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.
Correctly coding an aneurysm depends on the type and location, the specific vessels involved, and the presence or absence of associated complications such as ruptures. Each of these elements directly impacts code assignment, making detailed clinical documentation essential to ensure the conditions are accurately represented in the medical record. Note : To access this free article, make sure you first register if you do not have a paid subscription.
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CMS announced its A/B Medicare administrative contractors have withdrawn the local coverage determinations for skin substitute grafts/cellular and tissue-based products for the treatment of diabetic foot ulcers and venous leg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.
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?
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.
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.
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.
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.
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.
As we approach the end of the 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.
CMS recently published a fact sheet outlining an update coming from all seven Medicare administrative contractors to the local coverage determinations for skin substitute grafts/cellular and tissue-based products for the treatment of diabetic foot ulcers and venous leg ulcers, which will be effective January 1, 2026. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: What is the correct ICD-10-CM coding approach for poisoning cases that include documented manifestations, and how are these cases reflected in code selections and sequencing?
Coding for spinal fusions is very confusing, 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 Medical and Surgical section of the ICD-10-PCS to find where appropriate spinal fusion codes can be located.
The American Hospital Association recently released a report that found patient safety in hospitals and health systems across the nation has continued to improve. It also found that despite caring for a sicker patient population, the focus on safety has led to improved patient outcomes and reduced infections.
Heart arrhythmias are disorders of cardiac rhythm that occur when the heart’s electrical impulses do not function properly, resulting in rhythms that are too fast, too slow, or irregular. For coders, a strong understanding of arrhythmia types, applicable ICD-10-CM coding considerations, and key provider documentation requirements are needed to support accurate, compliant coding and appropriate HCC capture. Note : To access this free article, make sure you first register if you do not have a paid subscription.
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.
