Follow the career journey of Patricia Shirley, CPC-I, CPC , who started as a front office staff member and advanced through billing and coding roles before transitioning to the CDI field. Her experience highlights the benefits of adaptability and continuing education, demonstrating how a solid foundation in coding and compliance can help improve patient care and ensure accurate clinical documentation.
Physicians and other qualified healthcare professionals have the flexibility to select an evaluation and management level based on either the complexity of medical decision-making or the total time spent on the date of the encounter. This article covers documenting E/M services based on time. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
Black Book Research recently surveyed more than 4,000 health information management professionals about their concerns for the new year. Find out what issues are at the top of their minds for 2025.
The major revisions to the coding guidelines for office/other outpatient evaluation and management visits are almost four years old. And yet, practices continue to face challenges when they document and report these services. This article outlines four actions to avoid and four challenges that practices face when they report these high-value, high-volume services.
Level-based evaluation and management services may be coded based on medical decision-making (MDM). To reach a code based on MDM, the documentation must support at least two out of the three elements. This article covers the first element: number and complexity of problems addressed at the encounter.
Following questions from Congress on what steps the government should take to eliminate remaining barriers in accessing addiction treatment, the American Hospital Association noted two out of eight policy and regulatory barriers that currently impact inpatient facilities. Learn what the consequences could be if these barriers were addressed.
If denials are not going anywhere anytime soon, increasing at an alarming rate, and causing organizations to close, how do hospitals ameliorate this issue? Hospitals, including coders, can work to stem it by understanding the different types of denials, the problems they pose, and the tactics required to fight them.
Q: A female patient previously had an inpatient stay due to severe enteritis secondary to the use of Keytruda for colon cancer that she was diagnosed with six months earlier. While she has had positive results to the medication, she presented to the ER last week due to severe abdominal bloating and cramping with diarrhea and stools with large amounts of mucous. She was dehydrated and hypokalemic upon inpatient admission and has a history of depression. Her discharge note indicates that her potassium levels and dehydration are normalized. How would this encounter be reported in ICD-10-CM?
Because multiple organ disfunction syndrome does not have a specific ICD-10-CM code, coders face the challenge of capturing the full complexity of the condition. Nevertheless, understanding the various organ systems involved and recognizing the specific dysfunctions can help coders accurately report the condition. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Genetic medicine is an emerging specialty coders will be faced with, and a basic foundation of the science and consequences of genetic anomalies will be helpful going forward. Realizing coders are not expected to be clinical, Nancy Reading, RN, BS, CPC, CPC-P, CPC-I , shows how it will still be useful to know the basics.
Enhanced care management codes for advanced primary care management services in the physician fee schedule proposed rule have been cleared. This article discusses the terms billing providers and their teams must meet when providing these services.
Q: What were the AMA’s goals for revising evaluation and management (E/M) services that were implemented starting in January 2021 and continued in January 2023?
CMS recently issued a proposed rule for 2026 that includes provisions aimed at limiting Medicare Advantage in-network cost-sharing for behavioral health services to be no greater than the traditional Medicare rates. Find out what the proposed behavioral health cost-sharing standards are in the proposed rule.
Patients diagnosed with a malignant neoplasm, commonly known as cancer, are now living longer due to better treatments. In 2025, there are 47 new ICD-10-CM codes to be used to report lymphoma in remission. This article broadly reviews those new codes.
Coders should use particular care when selecting diagnosis codes, always selecting the most specific code possible, based on the clinician’s documentation. This article covers diagnosis coding guidelines to help avoid using vague or non-specific diagnosis codes that will likely result in denials. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
Marc Hartstein, MA , brings together all the major highlights of Medicare’s newest Inpatient Prospective Payment System, allowing coders to stay informed about key updates and navigate the changes throughout the year.
Health information management occupies a pinnacle position in the revenue cycle, and although the span of coding’s influence throughout a healthcare organization is very broad, its effects can also be found in numerous revenue cycle spokes, including preregistration and scheduling, coverage approvals, and case management. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Because substance use, abuse, and dependence are critical areas within healthcare that impact CDI and coding, Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , provides readers with an in-depth analysis of these conditions and emphasizes their clinical, diagnostic, and coding implications.
In a recent release published by the WHO and CDC, new estimates revealed cases of measles are surging worldwide due to inadequate immunization coverage. Coders should explore the implications of this outbreak, as they play a critical role in supporting healthcare systems manage vaccination efforts and protect public health.
