One of the challenges in coding personality disorders is that the terminology used in clinical documentation may not always match the formal diagnostic title listed in ICD-10-CM. Understanding the clarifying and inclusion terms associated with personality disorder codes helps ensure accurate code assignment, reduces the risk of miscoding similar-sounding disorders, and supports complete and compliant clinical documentation. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Coding professionals are fluent in classification systems such as ICD-10-CM/PCS and CPT, which translate documentation into standardized labels and codes for billing, reporting, and quality programs. Laboratory results, however, travel far beyond the claim. Pamela Banning, MLS (ASCP), PMP (PMI), delves into LOINC and SNOMED CT, two international coding systems applied within laboratory information systems to make lab results computable and consistent across computer systems.
Services provided in an inpatient setting are reported using two different coding systems. The facility reports procedures using ICD-10-PCS codes while the individuals providing the care report professional services using CPT codes. Terry Tropin, MSHAI, RHIA, CCS-P, provides a glimpse into how these two coding systems can work together in order to fully report inpatient services.
Q: When abnormal renal function is documented without a clear diagnosis, what clinical indicators should coders review to determine whether a provider query is warranted?
CMS recently published the fiscal year 2027 ICD-10-PCS code set and official guidelines. Although CMS made no significant changes to the guidelines, the ICD-10-PCS code set includes 101 new codes, 38 deleted codes, and one new table.
An angiography is a surgical intervention involving the vessels. In angiography procedures, catheters are manipulated into the body to the site of the procedure, dyes are injected, and images are taken.
A coding audit may be conducted by internal staff or external entities, typically representing the insurers paying for the care. When planning to implement a coding auditing program, the type of reviews, focus areas, and review frequency must all be taken into consideration. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
An outpatient care model designed to serve high-cost Medicaid patients was found to significantly reduce healthcare spending, hospital admissions, and emergency department visits, according to a study published in The American Journal of Managed Care.
Comorbid conditions or complications (CC) and major comorbid conditions or complications (MCC) indicate a higher level of severity of illness, an elevated risk of mortality, and an above average intensity of resource utilization. Given their impact on reimbursement and quality reporting, Nancy Reading, BS, CPC, CPC-P, CPC-I, emphasizes how success in coding CCs and MCCs requires a delicate balance of documentation specificity and clinical clarity in diagnosis assignment.
Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, explores the governmental scrutiny around risk adjustment documentation, coding, reporting, and accuracy following the release of a governmental report and press release.
Human immunodeficiency virus is a chronic viral infection with clinical manifestations that can range from an asymptomatic infection to AIDS, the most advanced stage of the disease. Because HIV-related diagnoses carry unique ICD-10-CM coding guidelines, coders must carefully review the medical record to determine whether the documentation supports assignment of HIV disease, asymptomatic HIV infection, or other HIV status, as well as the presence of any HIV-related illnesses.
A recent study published in the Journal of the American College of Surgeons suggests that postoperative physical activity levels measured by wearable devices were significantly associated with key surgical outcomes, finding that every 1,000 steps taken per day by patients after surgery is linked to fewer complications, lower readmission rates, and shorter hospital stays.
In a world full of denials, sometimes the best thing you can be is a denials specialist. However, only 11.66% of respondents to the 2025 ACDIS CDI Salary Survey reported that their department included a CDI denials specialist role.
Cerumen, or more commonly referred to as earwax, is made by the body to protect the ears. Cerumen has both lubricating and antibacterial properties against bacteria, fungi, and water. Code assignment for cerumen removal is based on whether the cerumen is impacted. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The COVID-19 pandemic kickstarted a shift in surgical care from the inpatient to outpatient setting due to elective surgeries in hospitals being suspended. The popularity of outpatient surgeries after the pandemic continued to grow, according to a study published in Medical Care Research and Review.
Preventive care is a system of tests and treatments designed to keep healthy people healthy. These services include the administration of immunizations and vaccines, as well as counseling for smoking cessation and nutritional guidance
