Assigning proper codes plays a role in the integrity of medical records, supports effective communication between healthcare providers, and safeguards a practice against compliance issues. This article discusses some common dermatological conditions and their respective ICD-10-CM codes/categories.
The concept of social determinants of health (SDOH) has transformed significantly, advancing from increased awareness to data integration and the development of tools and frameworks. This article explores the importance of integrating SDOH into the healthcare framework and the coding process, as well as best practices for leveraging this data to inform health interventions.
Medicare patients who qualify for the new preventive service designed to protect them from HIV will be eligible for up to eight counselling and screening services a year, according to a recently released CMS national coverage determination.
ICD-10-CM contains specific pain codes based on the type of prosthetic device, mesh, or implant. This article reviews best practices for using placeholders and selecting the correct encounter code, as well as other considerations when using diagnosis codes.
Revisions to the E/M guidelines have simplified documentation and eliminated unnecessary documentation. Clinicians may choose levels of E/M services based on time or level of medical decision-making. Nancy M. Enos, FACMPE, CPC-I, CPMA, CEMC, CPC emeritus , dives deep into both processes and provides best practices for each.
The American Medical Association recently announced new codes, deletions, and revisions included in the CPT 2025 code set. Explore these notable updates to the code set.
The connection between medical necessity and diagnosis coding should be included with your training on the 2025 update to the ICD-10-CM code set. This article serves as a refresher on medical necessity, possible ICD-10-CM conflicts, and other best practices.
Patients who self-reported housing instability often didn’t have the correct ICD-10-CM codes documented in their record, according to a recent study. Review the results of the study and be more aware of the importance of properly documenting housing insecurity to ensure appropriate housing and medical services are delivered.
The ICD-10-CM changes for fiscal year 2025 are coming October 1, 2024. Learn about some of the changes to guidelines, notes, wording in current categories, and expansion of code categories.
A recent draft local coverage determination includes detailed coverage requirements for chronic migraine treatment. This article reviews the terminology that drives migraine coding.
Q: What ICD-10-CM code should we report for a periprosthetic fracture due to an injury? Do you use the S codes for a traumatic fracture with a secondary code for replacement, or do you select a code from the M97 (Periprosthetic fracture around internal prosthetic joint) category?
Q: What are some of the common documentation pitfalls or missteps related to pediatric malnutrition? And what can CDI specialists do to address them proactively?
CMS finalized many behavioral health requirements related to social determinants of health risk assessments, care management services, and more with the 2024 Medicare Physician Fee Schedule final rule. With all these changes where do providers start?
Q: Is it appropriate to code metabolic encephalopathy related to alcohol withdrawal or alcohol withdrawal delirium? And if so, how do you successfully defend against denials?
Q: A specialty society's fact sheet offers guidance for determining E/M level when an ICD-10-CM social determinant of health code affected the diagnosis or treatment. What is Medicare's policy on this?
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , delves into ICD-10-CM and CPT coding for urogynecology, a subspeciality that provides necessary crossover care for female patients. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: Should signs, symptoms, or unspecified ICD-10-CM codes (e.g. M54.50 [low back pain, unspecified]) be reported when the condition (e.g. M51.36 [other intervertebral disc degeneration, lumbar region]) is also reported on the same outpatient encounter?
Nancy Reading, RN, CPC, CPC-P , explains how understanding liver disease and its many complications is key to supporting higher-specificity ICD-10-CM coding and reimbursement.
Q: How would a coder report the scenario of an unmedicated diabetic patient with diabetic renal nephrosis and out-of-control blood sugar during an encounter?
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , explains how to report neonatal respiratory failure, including meconium aspiration, failure to thrive, and associated symptoms in ICD-10-CM.
Tonya Chandler, RHIT , brings light to the declining mental health in youth, clarifies possible contributing factors, and explains how to report mental and behavioral conditions in ICD-10-CM with several case scenarios.
CMS proposed hundreds of ICD-10-CM code changes in the 2025 IPPS proposed rule, published April 10, including 252 new codes, 13 revised codes, 36 invalidated codes.
The Journal of the American Medical Association (JAMA) published a study in March found that “foot and ankle care was associated with an 11% lower likelihood of death…and a 9% lower likelihood of major amputation (above or below knee).”
C. diff results from a disruption of the normal bacterial flora of the colon. Recognize the diagnostic criteria, treatment, and ICD-10-CM coding tips for reporting this disorder. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Heart failure affects more than 6 million adults in the U.S. and costs the nation more than $30 billion. Review ICD-10-CM guidance and documentation details required for accurately reporting the condition. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, and Karla VonEschen, MS, CPC, CPMA, CCDS-O, take a look back at the progression of diagnosis and mortality coding before looking ahead to ICD-11 and how coding departments can prepare for it.
Teresa Seville, RHIT, CCS , explains that a thorough review of code updates must include analysis of the addenda, including index, tabular notes, guidelines, and committee meeting highlights.
Diane Pittman, CPC, CPMA, CRC, CCD-O, and April Russell, MBA, CPC, CPC-P, COC, CRC, CCDS-O , explain how reporting ICD-10-CM social determinants of health, their context, and coder feedback can influence natural language understanding.
Q: What terms need to be included in physician documentation to code in ICD-10-CM whether the patient’s migraine is chronic, intractable, or with status migrainosus?
Michael Malohifo’ou, RN, MBA, PhD , explains how excessive use of emergency departments can result in unfavorable outcomes . He also assesses the complicated relationships between EDs, social determinants of health ICD-10-CM coding, and mental and behavioral health CPT services.
Providers can receive additional revenue when they check a patient for social determinants of health, but the service requires patient selection, a standardized tool, and follow up. Julia Kyles, CPC, explains how practices can report this service with a new HCPCS code for 2024.
A recent Office of Inspector General audit of inpatient and outpatient Medicare claims estimated that nearly 20% of cases including codes for abuse or neglect were not reported to law enforcement.
Q: Are coders required to report a social determinants of health (SDOH) ICD-10-CM code when a CPT code for an E/M service level is based on medical decision-making (MDM)?
The 2024 ICD-10-CM update brought new codes to classify Lafora progressive myoclonus epilepsy and chronic migraines. Review the conditions, symptoms, causes, and reporting requirements of these disorders. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Craniosynostosis, a congenital premature fusion of cranial sutures in infants, poses a complex challenge to the child’s appearance and health. Debbie Jones, CPC, CCA , explains the condition, as well as how to report its many types in ICD-10-CM and associated surgical correction procedures in CPT.
The U.S. has experienced extreme weather events in recent years, including cataclysmic hurricanes and tornadoes. Terry Tropin, MSHAI, RHIA, CCS-P , explains how coders should use and sequence external cause codes in ICD-10-CM for injuries caused by these storms. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The 2024 Medicare Physician Fee Schedule proposed rule received more than 17,000 stakeholder comments. Julie Kyles, CPC , highlights some of the major concerns that commenters expressed, such as requests for more telehealth policy flexibility and community health integration services.
The 2024 ICD-10-CM update brings almost 400 code changes, including new codes for sickle-cell retinopathy and orbital muscle entrapment. This article delves into the causes, symptoms, and reporting methods for these two ocular conditions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
As coders witness annually, the ICD continues to evolve over its decades of use. This article covers the history of disease classification, current coding techniques, and possible future technologies of the industry. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Terry Tropin, MSHAI, RHIA, CCS-P , reviews the biggest changes to the 2024 ICD-10-CM guidelines and tabular list set to take effect October 1, including deletions of certain COVID-19 screening guidelines, and additional direction for new resistant hypertension and myocardial infarction codes.
As the summer temperatures continue to soar worldwide, so does the number of patients with heat-related illnesses (HRI). This article defines common HRIs and includes guidance on how to report them correctly in ICD-10-CM. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Chronic ulcers are a prolific, costly problem in hospitals. This article examines the most common types of chronic ulcers—diabetic, venous, and pressure ulcers—and the ICD-10-CM guidance coders should know to properly report them. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS released the fiscal year 2024 ICD-10-CM Official Guidelines for Coding and Reporting on July 5. The release included updated language and examples for reporting COVID-19 preoperative testing, sepsis, the coma scale, and other conditions.
Q: What are some tips for organizations that are just starting out capturing the type of information to report social determinant of health (SDOH) diagnoses in ICD-10-CM?
Sickle cell disease is a group of inherited disorders that causes red blood cell deformation. This article discusses the disease and covers new guidance for it and its manifestations according to FY 2024 ICD-10-CM guidelines and codes. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , covers the highlights from the Coding Clinic’s latest installment. It includes sequencing for cancer, COVID-19 screening updates, and analysis of “with” guidelines in ICD-10-CM.
Fentanyl and other synthetic opioids are the most common drugs involved in overdose deaths in the U.S. Tonya Chandler, RHIT , examines ICD-10-CM reporting for fentanyl use, overdose, symptoms, and dependence through several coding scenarios.
Coders saw extensive code changes and expansion for ICD-10-CM category O35.- in 2023. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG, reviews codes in Chapter 15, section E: Fetal conditions affecting the management of the mother.
This article defines types of hernias coders may encounter, including inguinal, femoral, congenital hiatus, congenital diaphragmatic, diaphragmatic hiatal, and what details coder will need to look for to accurately report them, per 2023 ICD-10-CM guidelines. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Atrial fibrillation is the most common type of cardiac rhythm disorder in the U.S. This article defines the condition, reviews relevant ICD-10-CM coding guidelines, and provides documentation and reporting guidance from experts. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS released the fiscal year (FY) 2024 IPPS proposed rule on April 10. The document contains proposals for 395 new, 12 revised, and 25 invalidated ICD-10-CM codes.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS , discusses how the 2023 ICD-10-CM guidelines update the instructions for reporting intraoperative care complications.
The beginning of March brought the release of the first quarter 2023 Coding Clinic . Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC, summarizes key information provided in this publication, including analysis of ICD-10-CM guidelines , code changes, and coding Q&As.
Hypothyroidism is a common chronic disorder that involves the underproduction of the thyroxine hormone. This article defines hypothyroidism, reviews relevant ICD-10-CM codes, and provides insight from experts. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Limb girdle muscular dystrophy is a group of genetic disorders that cause myopathy of the proximal shoulder and hip girdle muscles. This article reviews the disease, 2023 ICD-10-CM code updates, and relevant coding guidance. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Tonya Moton, RHIA, CCS, defines social determinants of health coding, explains the challenges of reporting these factors, and outlines how coders and providers can work together to create a positive impact in at-risk communities.
The Centers for Disease Control and Prevention and the National Center for Health Statistics published updates to the ICD-10-CM coding guidelines and files, which take effect April 1. The updates include 42 new diagnosis codes, seven deletions, and one revision.
A urinary tract infection (UTI) is a common bacterial disease that affects the bladder and urethra. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, reviews urinary anatomy as well as diagnostic considerations and ICD-10-CM coding for UTIs.
Diabetes mellitus is a chronic disease that causes elevated levels of glucose in the blood. It invades the body in many different ways. Shelley Safian PhD, RHIA, CCS-P, COC, CPC-I describes the types, manifestations, and treatment methods for diabetes mellitus and how to report them accurately in ICD-10-CM.
The 2023 ICD-10-CM update brought many new codes to report injuries sustained from collisions between motorcycles or electric-assisted bicycles and other vehicles, entities, or objects. This article reviews external cause codes and examines the new additions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Traumatic brain injuries (TBI) occur after blows, bumps, or jolts to the head disrupt normal brain function. This article covers new codes from the 2023 ICD-10-CM update that pertain to TBIs involving the skull and meninges. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Flail chest is the most severe type of blunt traumatic chest injury and is likely the most common serious thoracic injury. Debbie Jones, CPC, CCA, explains the symptoms, diagnostic process, and guidelines associated with reporting flail chest.
The 2023 update to the ICD-10-CM code set includes over 60 new codes for intracranial injuries with loss of consciousness, status known. This article covers codes from the 2023 ICD-10-CM update that pertain to traumatic injuries of the brain, specifically the cerebrum, cerebellum, and brainstem. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The ICD-10-CM Official Guidelines for Coding and Reporting provide a roadmap for accurate diagnosis coding. Kimberly Lee, M.Ed., RHIA, CCS-P, unpacks fundamental ICD-10-CM coding concepts.
The 2023 ICD-10-CM update, which took effect on October 1, includes almost 1,500 code changes. This article focuses on new codes in Chapter 9, Diseases of the Circulatory System. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The 2023 ICD-10-CM update features many new, revised, and deleted codes. This article focuses on code changes pertaining to blood/blood-forming organs including new codes for von Willebrand disease, heparin-induced thrombocytopenia, and platelet-activating anti-PF4 disorders.
Shelley Safian, PhD, RHIA, HCISPP, CCS-P, COC, CPC-I , describes how, beginning in 2023, medical decision-making (MDM) will be used to determine E/M leveling for additional visit services, following similar changes for outpatient visits implemented in 2022.
Q: New ICD-10-CM codes for unspecified vascular dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety take effect October 1. Do these new codes require linkage and specific documentation by the provider that the conditions are related?
Erectile dysfunction, sometimes called impotence, is a common male disorder. Debbie Jones, CPC, CCA covers physiology, symptoms, and treatment for erectile dysfunction, as well as associated ICD-10-CM and CPT codes.
Effective October 1, the ICD-10-CM code set will be updated to include over 1,100 new codes before counting code revisions and deletions. This article covers new codes for musculoskeletal and genitourinary conditions including muscle wasting, rib and sternal fractures, drug-induced neuropathy, and endometriosis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Each year, coders must review updates to the ICD-10-CM code set including new, revised, and deleted codes and reporting guidelines. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, explains that for 2023, coders will find several new codes in the “Mental, Behavioral, and Neurodevelopmental Disorders” chapter for dementia.
Because of the prevalence of eating disorders, coders should become familiar with their types, symptoms, codes, and relevant guidelines. They appear in ICD-10-CM under category F50 (eating disorders), but codes for individual symptoms appear throughout the manual. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
This article analyzes ICD-10-CM codes for diseases that can manifest from prolonged hypertension. These codes appear throughout the ICD-10-CM manual, but most are found in Chapter 9 (Diseases of the circulatory system). Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Hypertension, also known as high blood pressure, is a condition in which the force of blood exerted against the artery walls is higher than normal for a prolonged period. This article explains hypertension pathophysiology and ICD-10-CM coding for the condition. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS recently published its first quarter HCPCS Application Summaries and Coding Recommendations, which, included 22 requests to establish new HCPCS Level II codes for drugs and biologicals and CMS' final HCPCS coding decisions.
The Centers for Disease Control and Prevention recently released the fiscal year (FY) 2023 ICD-10-CM code set and ICD-10-CM Official Guidelines for Coding and Reporting. Review key ICD-10-CM updates including new codes for dementia, head injuries, and long-term drug therapy.
Many factors influence the identification of a primary diagnosis, including varying provider documentation styles and health record nuances. Holly Cassano CPC, CRC, navigates challenges that come with selecting an appropriate primary diagnosis code.
Hospital coding for wound procedures is notoriously difficult, as the process can seem as messy as the injuries themselves. Clarify wound documentation and guidance for reporting wound diagnoses and procedures using ICD-10-CM, CPT, and HCPCS Level II codes. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Determination of what is medically necessary for any given diagnosis is set forth by the healthcare industry’s Standard of Care. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , unpacks local and national medical necessity standards and best practices for avoiding denials due to inadequate documentation .
Bruxism, or excessive teeth grinding, is a common condition that is often brought on by stress and anxiety . Debbie Jones, CPC, CCA , describes the causes and symptoms of bruxism and ICD-10-CM coding for the condition.
Anxiety disorders are the most common mental illness in the U.S., according to the National Institute of Mental Health Statistics. Shelley Safian, PhD, RHIA, CCS-P, COC, CIC , breaks down ICD-10-CM coding for common types of anxiety disorders and psychotherapy treatments used to manage them. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Chapter 19 of ICD-10-CM includes codes for various types of injuries, poisonings, and other consequences of external causes. Review integumentary anatomy and ICD-10-CM coding for burns and superficial injuries. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The 2022 ICD-10-CM manual includes new codes for thrombotic microangiopathy (TMA)—a rare clinical syndrome defined by the presence of hemolytic anemia, organ dysfunction, and low platelets. Read up on TMA pathophysiology and diagnosis coding.
Coding for spinal diagnoses requires careful attention to detail. Take time to review spinal anatomy and ICD-10-CM coding for common diseases of the spinal column and paravertebral tissues. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
ICD-10-CM codes for traumatic fractures specify the type of bone injury, affected area of the body, and in some cases, the degree of soft tissue damage. Review orthopedic terminology and documentation requirements for traumatic fractures to resolve the coding challenges. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
