A TIA is typically a short-lived transient event that results in no permanent tissue damage or residual neurologic deficits. On the other hand, a stroke results from either a vessel blockage or a hemorrhage, causes some variety of tissue damage, and may leave residual neurologic deficits. Follow Nancy Reading, BS, CPC, CPC-P, CPC-I, as she explores the differences between these two conditions.
Identifying secondary diagnoses is an important part of accurately reflecting the patient’s overall condition and the care provided during an encounter. While the primary diagnosis represents the main reason for the patient’s visit or admission, secondary diagnoses capture additional conditions that require attention or have an impact on the patient’s care. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Q: What clinical factors distinguish acute skin failure from a pressure injury, and how should the two conditions be approached from an ICD-10-CM coding perspective?
Understanding the clinical findings associated with quadriplegia is an important first step in determining how the condition should be reported. After reviewing the causes and effects of quadriplegia and reportable ICD-10-CM codes for the condition, this article will dive into key physical examination findings and documentation considerations that can help further guide accurate code selection. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Q: What are the key characteristics of cachexia versus ASPEN-defined malnutrition, and what ICD-10-CM codes are available for reporting each condition?
Congenital heart defects are commonly encountered chronic conditions in pediatric coding and documentation, yet their presence alone does not ensure they are appropriately reported or fully understood within the clinical context of an encounter. Jenny Esper, RHIA, CCS, CDIP, CCDS, tackles the challenges of determining when a CHD is relevant to the admission and whether the documentation accurately reflects its clinical significance for proper coding.
A diagnosis of systemic lupus erythematosus is only the starting point. Accurate ICD-10-CM coding requires careful attention to the provider's documentation, including whether the lupus is drug-induced, whether specific organ or system involvement is documented, and whether additional codes are required. Note : To access this free article, make sure you first register if you do not have a paid subscription.
A newly released Office of Inspector General report estimates that Medicare Advantage organizations may have received nearly $462 million in improper payments after submitting unsupported acute stroke diagnosis codes to CMS. The findings highlight ongoing concerns about documentation quality and diagnosis validation in risk adjustment reporting.
With insight from Lynette Byerly, BSN, RN, CCDS, CCS, coders can discover how CDI specialists bridge the clinical world to the realm of coding and reporting, especially when pediatric conditions are not always easily reportable.
Beyond capturing primary and secondary diagnoses, what goes into a record can hugely impact how a patient is cared for both now and in the future, as well as the trajectory of a community’s health at large. See why it’s essential to go beyond surface-level knowledge and gain a true understanding of how and why SDOH data is important to track, especially for pediatric patients.
Drug overdose deaths in the United States declined for the third consecutive year in 2025, according to preliminary data released by the Centers for Disease Control and Prevention. The decline marks the longest sustained reduction in overdose deaths in decades and brings the national total back to roughly the level seen in 2019, before the COVID-19 pandemic.
Accurate coding for liver failure requires much more than selecting the correct ICD-10-CM code—it demands an understanding of liver function, disease progression, clinical indicators, and documentation nuances. Note : To access this free article, make sure you first register if you do not have a paid subscription.
This article examines two examples—bone marrow transplantation and lung transplantation—to illustrate the similarities and differences in coding transplant encounters. These examples demonstrate how transplant coding is largely driven by transplant status, the reason for the encounter, and the presence or absence of transplant-related complications, while highlighting the unique coding considerations associated with specific transplant types. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Respiratory syncytial virus and COVID-19 are both types of respiratory viruses, and the symptoms can be very similar and overlap each other. Shontia Leon-Guerrero, CPC, CEDC, CEMC, CPC-I Educator, reviews the signs and symptoms of both conditions in infants and children as well as what coders need to know such as diagnosis codes, procedure codes for vaccine administration, and documentation expectations.
One of the challenges in coding personality disorders is that the terminology used in clinical documentation may not always match the formal diagnostic title listed in ICD-10-CM. Understanding the clarifying and inclusion terms associated with personality disorder codes helps ensure accurate code assignment, reduces the risk of miscoding similar-sounding disorders, and supports complete and compliant clinical documentation. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Human immunodeficiency virus is a chronic viral infection with clinical manifestations that can range from an asymptomatic infection to AIDS, the most advanced stage of the disease. Because HIV-related diagnoses carry unique ICD-10-CM coding guidelines, coders must carefully review the medical record to determine whether the documentation supports assignment of HIV disease, asymptomatic HIV infection, or other HIV status, as well as the presence of any HIV-related illnesses.
Comorbid conditions or complications (CC) and major comorbid conditions or complications (MCC) indicate a higher level of severity of illness, an elevated risk of mortality, and an above average intensity of resource utilization. Given their impact on reimbursement and quality reporting, Nancy Reading, BS, CPC, CPC-P, CPC-I, emphasizes how success in coding CCs and MCCs requires a delicate balance of documentation specificity and clinical clarity in diagnosis assignment.
Diagnosing opportunistic infections can be particularly challenging because the presenting signs and symptoms are nonspecific and may resemble a wide range of other conditions, making it difficult for providers to immediately identify the exact infectious process. Nevertheless, coders should recognize how clear documentation of both the infection and the underlying pathogen is particularly critical for proper code selection as many ICD-10-CM codes are organism-specific and dependent on the anatomical site or body system involved. Note : To access this free article, make sure you first register if you do not have a paid subscription.
