Updated coding guidance can be found in CMS’ Medicare Preventive Services educational tool for several services. Review the changes to ensure proper coding of preventive services.
The Agency for Healthcare Research and Quality has released the 2025 Patient Safety Indicators (PSI) updates and revisions. Review the changes in more detail and discover which outdated indicators have been removed and which indicators have been modified.
Respiratory failure is a life-threatening condition that occurs when the respiratory system is unable to maintain adequate gas exchange. Accurate coding of this condition ensures that healthcare providers can effectively communicate the severity of the condition, track patient outcomes, and avoid misclassification. Note : To access this free article, make sure you first register if you do not have a paid subscription.
It is not unusual for a professional medical coder to determine the need for multiple ICD-10-PCS procedure codes to tell the whole story about the care a patient has received during a current admission. Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I , shows how to begin by first referring to sequencing guidelines for principal and secondary ICD-10-CM diagnosis codes.
Learn how HIM professionals, including coders, can leverage data related to social determinants of health to improve patient care and secure proper reimbursement.
According to the National Multiple Sclerosis Society, almost one million people in the United States have been diagnosed with multiple sclerosis (MS), a chronic autoimmune neurological disorder. Discover how to code the diagnostic tests for MS, the varieties of the disorder, and treatments for it.
Medicare pays for therapy services when the medical record and the information on the claim form accurately report covered therapy services. That means your documentation must be legible, relevant, and sufficient to justify the services billed. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The implementation of the 21st Century Cures Act has resulted in radiology patients in the outpatient setting being able to view their examination results quicker, according to a study published in JAMA Network Open.
While many bone fractures are often treated in emergency rooms or orthopedic clinics, certain fractures—especially severe, complex, or high-risk ones—tend to require inpatient admission. Nancy Reading, BS, CPC, CPC-P, CPC-I , shows how recognizing severity of fractures that may warrant hospitalization helps coders capture the full scope of the patient’s condition.
Machine learning (ML) has evolved beyond its status as a technological trend to become an indispensable asset in outpatient surgical risk stratification. Within the domains of medical coding and claims adjudication, coding professionals play a pivotal role in optimizing ML model performance.
It is not unusual for a professional medical coder to determine the need for multiple ICD-10-PCS procedure codes to tell the whole story about the care a patient has received during a current admission. Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I , shows how to begin by first referring to sequencing guidelines for principal and secondary ICD-10-CM diagnosis codes.
CDI departments are focusing on pediatric populations through various unique initiatives, particularly with the intent to establish organizational definitions for certain diagnoses and expand clinical knowledge of intensive neonatal care. Such initiatives can support the clinical validation of reported codes and encourage good relationships with providers in case queries are needed.
The Outpatient Code Editor (OCE) provides the answers to the test, but to use it effectively, you need to understand the history and the complex configuration of all the parts.
The pelvis encloses and supports the internal organs, so a pelvic ring fracture—commonly caused by traumatic events such as car crashes—can trigger extensive internal bleeding and other injuries. Learn about some CPT fracture codes for posterior pelvic ring fractures that would be reported in many trauma situations.
Our experts answer questions about diabetes mellitus in remission, percutaneous versus endoscopic discectomies, and complicated and uncomplicated problems.
Our experts answer questions on better coding and CDI collaboration for escalation processes and AI implementation, queries for undocumented diagnoses and cause-and-effect relationships, and codes for hemorrhages as surgical complications.
