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.
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.
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.
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.
A neonatal intensive care unit offers very specialized medical services and treatments to premature and critically ill neonates (i.e., babies 28 days old or younger). Review which ICD-10-CM and CPT codes may be used for providers assisting in this type of care.
Take three steps when an assistant surgeon helps during a procedure. First, make sure an assistant-at-surgery modifier is appropriate for the procedure. Second, make sure the primary surgeon’s note explains why they needed the help of a qualified healthcare professional (QHP) or another physician for the procedure. Third, make sure you select the correct modifier, based on the assistant’s credentials and role.
Our experts answer questions about the multiple sclerosis medication administration, coding a crack cocaine overdose, and Medicare administrative contractors.
From concussions and cerebral contusions to complex intracranial hemorrhages and traumatic brain injuries, major head injuries encompass a wide spectrum of clinical presentations and outcomes. Because of their complexity and potential for lasting impact, complete and compliant ICD-10-CM coding is essential to reflect the full clinical severity of these conditions. Note : To access this free article, make sure you first register if you do not have a paid subscription.
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.
A prognostic study published in the Journal of the American Medical Association raises concerns that AI models designed to predict hospital outcomes may appear far more accurate than they truly are due to a subtle but serious methodological error known as label leakage.
Addressing the reliability of documentation, coding, and clinical reasoning underlying PSI flags is not simply a clinical safety imperative; it is a strategic business imperative. Priscilla Marlar, MHA, CSSBB, CPHQ, and John W. Cromwell, MD, suggest that achieving high reliability in quality data integrity starts with understanding the nuances of clinical documentation language and how those nuances are translated by CDI and coding teams into hospital billing codes.
Q: How do ICD-10-CM T codes work together with Z, F, and Y codes to fully capture drug-related conditions, and in what order should these codes be sequenced?
Part B providers are facing a radically different reimbursement landscape in 2026. In the 2026 Medicare Physician Fee Schedule final rule, CMS moved ahead with many of the changes it floated in the proposed rule, including fundamental changes to how the conversion factor is calculated, relative value unit valuation, payments for skin substitutes, and more.
CMS released the fiscal year 2026 ICD-10-CM files for use for discharges and patient encounters occurring from April 1 through September 30, 2026. Take time to review the updates. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
A study recently published in JAMA Network Open examined trends in outpatient mental health care among Medicare fee-for-service beneficiaries before, during, and after the COVID-19 pandemic.
A neonatal intensive care unit offers very specialized medical services and treatments to premature and critically ill neonates (i.e., babies 28 days old or younger). Review which ICD-10-CM and CPT codes may be used for providers assisting in this type of care.
Q: What are the most common reasons postpartum hemorrhage is documented and coded inconsistently, and how can coders and clinicians help address these issues?
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.
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.
