Three newly released compliance audits highlight significant gaps between high-risk diagnosis codes submitted for Medicare Advantage risk adjustment and the medical records supporting those diagnoses. Across the three organizations, OIG found that 533 of 700 sampled enrollee-years lacked sufficient medical-record support for certain submitted diagnosis codes and estimated approximately $202.2 million in overpayments.
Terry Tropin, MSHAI, RHIA, CCS-P, focuses on the less extensive changes of the fiscal year 2027 ICD-10-CM update for conditions that received only a handful of new codes but are nonetheless important for accurate and specific code assignment. Although these additions may be easy to overlook among the larger expansions to the code set, they provide new opportunities to capture conditions and clinical circumstances with greater precision.
Hepatic encephalopathy is a neurologic complication of severe liver disease in which impaired liver function allows toxic substances that are normally metabolized and eliminated by the liver to accumulate in the bloodstream and reach the brain. For coders, understanding the relationship between hepatic encephalopathy, the underlying liver disease, presence of a coma, and liver transplant complications is essential for accurately capturing the patient’s clinical picture and assigning the most appropriate ICD-10-CM codes. Note : To access this free article, make sure you first register if you do not have a paid subscription.
As coding teams collaborate across regions and contribute to shared quality and artificial intelligence evaluation initiatives, a common framework for measuring coding quality becomes essential. Without common evaluation principles, coding decisions may be difficult to compare, benchmark, or use for AI evaluation. Shera Stack, MSN, RN, CRC, and April Russell, MBA, CCDS-O, COC, CPC, CPC-P, CRC, consider how a common approach built around agreement, accuracy, defensibility, and truth provides the foundation for meaningful quality assessment.
Q: How can queries play a role in clarifying malnutrition and cachexia diagnoses while ensuring the patient’s condition is reflected in the medical record accurately for proper coding?
Hypertensive heart disease results from untreated or under-treated hypertension, causing a range of physiologic changes affecting the left atrium, left ventricle, and coronary arteries. Nancy Reading, BS, CPC, CPC-P, CPC-I, delves into the progression of hypertension to heart failure and shows how accurate code assignment and sequencing of the two conditions rely on the reason for admission and the relationships established among the patient’s conditions as documented by providers.
CMS recently published the fiscal year 2027 ICD-10-CM Official Guidelines for Coding and Reporting to accompany the ICM-10-CM update, effective October 1. Coders should note the clarifications and revisions added to several areas of the guidelines, specifically as it relates to sepsis, cancer treatment, hypertension, genetic disorders, and Z codes.
Lysosomal storage disorders are a group of rare, inherited metabolic disorders caused by genetic mutations that affect the normal function of lysosomes, or the structures within cells that contain enzymes responsible for breaking down and recycling various substances, including fats, sugars, proteins, and other cellular materials. Review some of the major categories in which commonly encountered lysosomal storage disorders are classified. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Q: How should a coder handle the documentation and coding of a fragility fracture when the underlying cause, such as osteoporosis, has not been clearly established?
Pediatric coding requires a fundamentally different lens than adult coding, as children represent a uniquely complex population with evolving physiology, age-dependent clinical norms, congenital influences, and a heavy reliance on caregiver-reported history. With this in mind, Renee Beus, MSN, RN, NCSN, outlines why pediatric coding cannot always follow adult frameworks, highlights common documentation pitfalls, and identifies what organizations must prioritize when building reliable pediatric coding and CDI programs.
Artificial intelligence (AI) is changing medical coding workflows. AI-assisted technology can help coding professionals work more efficiently. But there is an important distinction between identifying a possible code and determining whether that code should actually be reported.
Practices that perform allergy testing take note: A uniform allergy diagnostic testing policy for Medicare Part B patients will go into effect in 38 states as soon as September 27.
The AMA recently announced that the 2027 CPT code set includes 299 new codes, 74 revisions, and 80 deletions coming to a variety of services. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Identifying secondary diagnoses is an important part of accurately reflecting the patient’s overall condition and the care provided during an encounter. While the primary diagnosis represents the main reason for the patient’s visit or admission, secondary diagnoses capture additional conditions that require attention or have an impact on the patient’s care. Note : To access this free article, make sure you first register if you do not have a paid subscription.
A TIA is typically a short-lived transient event that results in no permanent tissue damage or residual neurologic deficits. On the other hand, a stroke results from either a vessel blockage or a hemorrhage, causes some variety of tissue damage, and may leave residual neurologic deficits. Follow Nancy Reading, BS, CPC, CPC-P, CPC-I, as she explores the differences between these two conditions.
Society is working hard to eliminate or reduce the stigma associated with the need for psychological healthcare services. Some patients require more intensive treatment and focused care, and the services provided during these inpatient stays are reported using codes from ICD-10-PCS, specifically those found in Section G. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, provides an in-depth review of this section and the many services that can be reported.
A report issued by the Centers for Disease Control and Prevention found that 15.2% of U.S. pregnant women reported current alcohol consumption during the past 30 days. The report, which examined 2021–2024 data from the Behavioral Risk Factor Surveillance System, also found that 4.9% of pregnant women reported binge drinking and 2.2% reported heavy drinking.
Q: What clinical factors distinguish acute skin failure from a pressure injury, and how should the two conditions be approached from an ICD-10-CM coding perspective?
