Reporting aneurysm repairs can appear almost as complex as the procedure itself. However, Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , shows how taking it one character at a time and using the helpful guidelines and descriptors provided within ICD-10-PCS will allow coders to master this accurately and quickly.
With its enhanced specificity and comprehensive structure, ICD-11 offers a more detailed and accurate framework for documenting cancer diagnoses. Karla VonEschen, MS, CCDS-O, CPC, CPMA , explores how precise documentation and the coder’s ability to capture all the diagnosis codes to fully describe the condition will be crucial for healthcare organizations.
Our experts answer questions on organizing clinical validation queries, the difficulty of diagnosing skin failures, and establishing an organizational definition of sepsis.
Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM , walks through the evolution of sepsis definitions that reflect the growing sophistication in our understanding of how the body responds to infection. Understanding the history not only helps contextualize definition variations in provider documentation but also has important implications for coding and reimbursement.
Catherine O’Leary, RN, BSN, CCDS , suggests that those who begin with manual coding and DRGs often develop a stronger, more intuitive foundation in CDI and how integrating manual training into a modern CDI program doesn’t mean abandoning technology. Her insights may prove valuable to coders who may increasingly find themselves working at the intersection of coding and CDI.
Our experts answer questions on the role of prior encounters in queries, coding neoplasms in transplanted organs, and workflows for reporting malnutrition and pathology.
Psychosis often emerges or is managed in outpatient mental health settings, but it can be coded during inpatient hospital stays due to the acute nature of the condition when it reaches a crisis point. To ensure that this mental health diagnosis receives the same diligence as medical and surgical diagnoses, Nancy Reading, RN, BS, CPC, CPC-P, CPC-I , provides coders with guidance on finding the right codes and resolving documentation conundrums.
Anemia is a complex condition to manage clinically and document accurately, yet proper diagnosis, documentation, and coding are critical for ensuring appropriate patient care and reimbursement. Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , explores the clinical aspects of anemia, including its definitions, types, causes, and management, while addressing the challenges in clinical documentation and coding.
AI is increasingly being integrated into the CDI industry and as these tools evolve, their capabilities will naturally extend into adjacent fields like medical coding. Although AI may not be an entirely welcome change, Sarah Matacale, BSN, RN, CCS, CCDS , highlights practical ways CDI professionals and even coders can adapt to and benefit from these new tools.
