AI is no longer a distant concept in medical coding and health information management; it is already part of daily work. For many professionals, daily encounters with AI bring a mix of curiosity, caution, and concern.
Accurately telling the patient’s story requires a thorough review of the entire medical record to identify all conditions that were addressed during the encounter, whether directly or indirectly, by the provider.
CMS recently published the fiscal year 2027 ICD-10-CM code set for discharges and patient encounters occurring from October 1, 2026 through September 30, 2027.
Preventive care is a system of tests and treatments designed to keep healthy people healthy. These services include the administration of immunizations and vaccines, as well as counseling for smoking cessation and nutritional guidance
ICD-10-CM coding guidelines instruct providers to report a code through the entire fracture healing process—changing only the seventh character to signal the stage of healing. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
A greater telemedicine uptake among mental health specialists did not result in improved access to care for patients in communities with specialist shortages, according to a study published in JAMA Open Network.
Q: A patient presents with acute respiratory failure with hypoxia due to an accidental heroin overdose. What is going to be sequenced first: the acute respiratory failure or the poisoning?
For CPT and ICD-10-CM coding of fracture treatment, coders—particularly those in orthopedic practices—need to identify several vital pieces of information from the physician’s note. This article covers the keys pieces of information and other tips to ensure accurate coding of fracture treatment.
A neonatal intensive care unit offers very specialized medical services and treatments to premature and critically ill neonates (i.e., babies 28 days old or younger). Review which ICD-10-CM and CPT codes may be used for providers assisting in this type of care.
CMS released the fiscal year 2026 ICD-10-CM files for use for discharges and patient encounters occurring from April 1 through September 30, 2026. Take time to review the updates. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Medical coders work with many different code sets including CPT, HCPCS, ICD-10-PCS, and ICD-10-CM. This means coders need to be well-versed in medical terminology. One terminology not often talked about in coding circles is the Systematized Nomenclature of Medicine Clinical Terms—despite the system being around for more than 20 years.
Q: A patient was initially treated for extensive burns on his lower back and the posterior side of both thighs. The physician documented that the patient had second- and third-degree burns of the lower back (2% Total Body Surface Area [TBSA] second-degree and 7% TBSA third-degree) and third-degree burns of both thighs (9%). What ICD-10-CM codes would be assigned for this encounter?
Social determinants of health (SDOH) are critical for the well-being of the patient and are often more important than what occurs in physician’s offices, laboratories, operating rooms, and other clinical settings. Accurately capturing SDOH and providing education on doing so are equally critical for patient care, quality reporting, and reimbursement.
As we approach the end of the year, take a moment to refresh yourself on the ins and outs of the primary code sets an outpatient coder needs to understand and use in their role. This article provides a brief overview of three code sets that will serve as a review for veteran coders or a solid base of information for new coders.
