ICD-10-PCS coding for procedures performed within the cranial cavity is complicated. Terry Tropin, MSHAI, RHIA, CCS-P, describes the different body part values used for the brain and cranial cavity, root operations used, and coding for some common procedures.
Q: How are stroke intervention procedures like angioplasty, transfemoral carotid artery stenting, and transcarotid arterial catheterization coded using ICD-10-PCS, and how does ICD-10-PCS handle the coding of new technology devices?
At the recent public ICD-10 Coordination and Maintenance Committee Meeting, the Centers for Disease Control and Prevention National Center for Health Statistics discussed a draft proposal involving an expansion of sepsis diagnosis coding. Review the updates being considered for implementation on April 1, 2027. Note : To access this free article, make sure you first register if you do not have a paid subscription.
A report published by the American Cancer Society found that colorectal cancer rates among adults younger than 65 continue to increase while rates for older adults continue to decline. The study found that the increase is being driven by a higher prevalence of rectal cancer, which now makes up 32% of all colorectal cancer diagnoses, up from 27% in the mid-2000s.
Porcelain aorta is a disease that is caused by severe and widespread hardening of the walls of the ascending aorta that reaches to the aortic arch and descending aorta. Although there are several methods used to diagnose porcelain aorta, Brandi Hutcheson, RN, MSN, CCM, CCDS, CCA, says there is not a clear consensus on how it should be diagnosed.
According to data from the Centers for Disease Control and Prevention, the U.S. recorded 649 maternal deaths in 2024. While the total number of deaths declined slightly from 669 deaths in 2023, the overall maternal mortality rate showed no statistically significant improvement, highlighting ongoing challenges in maternal health outcomes.
Recovery auditors and payers have demonstrated an eagerness to exploit what providers routinely state in the medical record to facilitate additional DRG validation and medical necessity denials. Therefore, knowing what should not be said in a medical record is worth reviewing. To illustrate, Trey La Charité, MD, FACP, SFHM, CCS, CCDS, lists 10 things providers should never be documenting in the medical record.
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.
Q: What steps should medical coders take to correctly code adverse drug effects in ICD-10-CM, and when should a provider query be submitted if documentation is unclear or unspecific?
From an inpatient coding perspective, vascular dementia may be documented for hospitalized patients because it coexists with other acute or chronic medical conditions. Accurate coding of the condition and its associated risk factors and complications will ensure the patient’s overall severity of illness and complexity of care are fully captured. Note : To access this free article, make sure you first register if you do not have a paid subscription.
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.
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.
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.
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.
Review a study based on ICD-10-CM data from the National Vital Statistics System that shows life expectancy for the United States population increased to 79.0 years in 2024 while the mortality rate decreased by 3.8% to 722.1 deaths per 100,000 of the standard population in 2024. Also determined were leading causes of death.
Q: Why is pediatric malnutrition frequently underdocumented, and how can collaborative workflows improve documentation and coding accuracy as well as reduce queries?
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.
Insurance companies are increasingly challenging the translation from the medical record to prebill coding, making the financial impact of denials and downgrades one of the most pressing issues facing health systems today. Given the wide-ranging harm occurring from delayed and reduced reimbursement, Dawn Valdez, RN, CCDS, CDIP, highlights how coders and CDI specialists can play a key role in decreasing denials and downgrades as well as successfully disputing these actions.
