Inpatient coders know that clinical indicators for certain conditions frequently require greater completeness or specificity in ICD-10-CM for which a concurrent or retrospective query is often required. This article will review clinical indicators and query opportunities for common respiratory conditions such as pneumonia, respiratory failure, and asthma.
Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM, says that when reporting sepsis in ICD-10-CM, it’s important that evidence of sepsis is found throughout the body of a patient’s medical record. A clinical validity query may be necessary if the provider confirms the diagnosis of sepsis, but clinical evidence is lacking in the documentation.
Susan Belley, M.Ed., RHIA, CPHQ, and Audrey Howard, RHIA, write that a majority of inpatients during this omicron surge are admitted for reasons other than COVID-19 and are incidentally found to be COVID-19-positive—making this an opportune time to review ICD-10-CM reporting for COVID-19 as a secondary diagnosis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Jillian Harrington, MHA, CPC, CPC-I, CPC-P, CCS, CCS-P, CEMC, MHP, writes that in order to ensure proper coding, documentation, and reimbursement, it’s great practice to have inpatient coding and CDI teams review querying procedures yearly. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Most risk adjustment models use ICD-10-CM codes to identify patients who are considered “risky” by healthcare insurance companies. The process of risk adjustment is used to predict costs linked to care delivery and quality reporting, which is why thorough knowledge of risk adjustment is important for hospitals to ensure proper quality reporting.
Sarah A. Nehring, RHIT, CCS, CCDS , writes that with new COVID-19 codes coming in April 2022, now is a good time to review these updates as well as an ICD-10-CM code that was previously released in an April update: electronic cigarette, or vaping, product use-associated lung injury (EVALI). Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC, MSHIM, RHIA , writes that one diagnosis in particular that can take extra effort to understand is acute kidney injury (AKI). Frequently reviewing coding and CDI challenges related to AKI will ensure proper coding and reimbursement.
Sarah Nehring, RHIT, CCS, CCDS, says ICD-10-CM reporting for diabetes can be complex, that’s why it’s important for inpatient coders to regularly review reporting requirements for this diagnosis and associated complications. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Due to the drug ivermectin’s uptick in misuse for treating COVID-19, Susan Belley, MEd, RHIA, CPHQ, reviews ICD-10-CM reporting for poisonings, adverse and toxic effects, and underdosing. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Sarah Nehring, RHIT, CCS, CCDS , shares insight on the clinical concepts behind new fiscal year 2022 ICD-10-CM code I5A (non-ischemic [non-traumatic] myocardial injury) and Coding Clinic, Third Quarter 2021, advice regarding myocardial infarctions due to in-stent stenosis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
In this article, Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC, MSHIM, RHIA , breaks down a clinical scenario and corresponding query so inpatient coders and CDI specialists can better work to ensure proper reporting and reimbursement for diagnoses related to acute tubular necrosis (ATN).
In part two of this two-part series, Audrey Howard, RHIA, covers fiscal year (FY) 2022 updates to ICD-10-PCS reporting for spinal procedures, specificity updates to the ICD-10-CM official coding guidelines, and modified MS-DRG logic for type 2 myocardial infarctions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
In this article, we will take a closer look at clinical indicators for acute myocardial infarction, congestive heart failure, and arrythmias. Frequently reviewing clinical indicators for complicated diagnoses such as these will ensure both proper ICD-10-CM reporting and reimbursement.
In part one of this two-part series, Audrey Howard, RHIA, covers fiscal year (FY) 2022 updates to ICD-10-CM reporting for non-ischemic myocardial injury and traumatic brain compression and herniation. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Sarah Nehring, RHIT, CCS, CCDS, writes that in light of the fiscal year 2022 ICD-10-CM update to encephalopathy, now is a good time for inpatient coders to review common forms of encephalopathy and its reporting. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC, MSHIM, RHIA, writes that CDI professionals and inpatient coders need to pay attention to the definitions and clinical indicators of acute kidney injury (AKI) to ensure proper ICD-10-CM reporting and reimbursement.
Through examples given within the wound care setting, Bobbie Starkey, RHIT, CCS-P , shows the importance of documentation and ICD-10-CM reporting to support hierarchical condition category (HCC) capture within the inpatient coding sphere. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Sarah Nehring, RHIT, CCS, CCDS, writes that ICD-10-CM/PCS reporting for the cardiac system is complex and requires frequent review in order to report the most accurate codes. In this article, Nehring covers ICD-10-CM/PCS coding and clinical indicators for cardiogenic shock, intra-aortic balloon pumps, and more. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
In this article, Laurie L. Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC, reviews Coding Clinic , Second Quarter 2021, advice for reporting encephalopathy, a laparoscopic salpingo-oophorectomy, and more.
Sarah Nehring, RHIT, CCS, CCDS , reviews ICD-10-CM reporting and clinical criteria for various types of heart failure including diastolic, systolic, hypertensive, and more. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
