Copy-and-paste functionality is a documentation integrity issue with clinical, financial, legal, and quality implications. Maria Anaizza Aurora Reyna, MD, explores how collaboration between CDI teams and physician advisors can ensure the medical record evolves with the patient, supports accurate coding and clinical validation, withstands external scrutiny, and ultimately tells the patient’s true story across the continuum of care.
Start with the three key changes to the lower extremity revascularization CPT codes when you train staff on this major update, before you delve into more detailed guidance.
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.
Our experts answer questions on clinical recognition of pediatric malnutrition, query opportunities for unclear drug documentation, and clinical validation of tumor lysis syndrome.
For CPT and ICD-10-CM coding of fracture treatment, coders—particularly those in orthopedic practices—need to identify several vital pieces of information from the physician’s note. This article covers the keys pieces of information and other tips to ensure accurate coding of fracture treatment.
The CPT manual includes many types of biopsies: fine needle aspiration (FNA), core needle, and skin (tangential, punch, and incisional). This article focuses mainly on FNA biopsies and its complicated guidelines, while also touching on core needle biopsies.
Our experts answer questions about behavioral health coding, internal coding audits, and coding non-emergency services provided in the emergency department.
Immunoglobulin G4-related disease is a chronic immune-mediated fibroinflammatory disorder that often manifests with tumor-like masses and/or painless enlargement of multiple organs. Shontia Leon-Guerrero, CPC, CEDC, CEMC, CPC-I Educator, explores the general manifestations of the disease, its signs and symptoms, as well as key documentation tips and a coding scenario.
Review a study published in the Journal of the American Medical Association that suggests respiratory syncytial virus poses a far greater long-term health risk to adults in the months following hospitalization than previously understood due to increased risks of complications for myocardial infarction, stroke, chronic obstructive pulmonary disease exacerbation, congestive heart failure exacerbation, and arrhythmia.
When planning to implement a coding auditing program, the type of reviews, focus areas, and review frequency must all be taken into consideration, as each facet impacts the level of staffing required to conduct the reviews. Coding auditors should pick a few key elements to review, and the items should be of importance to your organization. Ideally, the topics will focus on issues that are frequent or require reassurance. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Neonatal intensive care units provide care and additional medical attention for neonates who might be born prematurely, with low birthweight, with a medical complication, or with a congenital anomaly. Follow Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, as she delves into common services performed in these units and how they are reported with ICD-10-PCS codes.
Immunoglobulin G4-related disease is a chronic immune-mediated fibroinflammatory disorder that often manifests with tumor-like masses and/or painless enlargement of multiple organs. Shontia Leon-Guerrero, CPC, CEDC, CEMC, CPC-I Educator, explores the general manifestations of the disease, its signs and symptoms, as well as key documentation tips and a coding scenario.
The February 4 issue of CMS’ MLN Matters outlines the January 2026 update to the hospital OPPS, including COVID-19 CPT code changes; new HCPCS codes for drugs, biologicals, and radiopharmaceuticals; and new unlisted skin substitute product HCPCS codes. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
For CPT and ICD-10-CM coding of fracture treatment, coders—particularly those in orthopedic practices—need to identify several vital pieces of information from the physician’s note. This article covers the keys pieces of information and other tips to ensure accurate coding of fracture treatment.
Practitioners work hard, especially when they perform critical care services. Training clinical and coding staff with real-world examples can make sure providers get full credit for their work. Share this case with staff and ask them to decide what services can be reported.
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.
Coders and billers may struggle to understand what the term medical necessity really means. Unfortunately, these two words can easily lead to misinterpretation and misunderstanding of what needs to be clearly communicated in a variety of healthcare areas. Learn common definitions of medical necessity, report types utilized in inpatient settings, and a query process in case more clinical detail is required. Note : To access this free article, make sure you first register if you do not have a paid subscription.
