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.
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.
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.
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.
A prognostic study published in the Journal of the American Medical Association raises concerns that AI models designed to predict hospital outcomes may appear far more accurate than they truly are due to a subtle but serious methodological error known as label leakage.
From concussions and cerebral contusions to complex intracranial hemorrhages and traumatic brain injuries, major head injuries encompass a wide spectrum of clinical presentations and outcomes. Because of their complexity and potential for lasting impact, complete and compliant ICD-10-CM coding is essential to reflect the full clinical severity of these conditions. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Due to all of the possible scenarios that come with a pregnancy, the reporting of ICD-10-CM diagnosis codes must reveal the specific risks patients have so that procedures, services, and treatments can all be supported. Follow Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I, as she outlines best practices for specifically reporting high-risk pregnancies.
Q: How do ICD-10-CM T codes work together with Z, F, and Y codes to fully capture drug-related conditions, and in what order should these codes be sequenced?
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.
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.
Correctly coding an aneurysm depends on the type and location, the specific vessels involved, and the presence or absence of associated complications such as ruptures. Each of these elements directly impacts code assignment, making detailed clinical documentation essential to ensure the conditions are accurately represented in the medical record. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Q: What are the most common reasons postpartum hemorrhage is documented and coded inconsistently, and how can coders and clinicians help address these issues?
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?
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.
With the start of a new 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.
Accurate provider documentation is the foundation of compliant coding, appropriate reimbursement, and defensible claims. Yet, in a rapidly changing healthcare landscape, even highly skilled clinicians can find it difficult to stay current.
Our experts answer questions on sorting through problem lists for the principal diagnosis, coding poisonings with resulting manifestations, and capturing loss of consciousness status.
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.
Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I, shows how reporting perinatology procedures with ICD-10-PCS is essential to accurately reflect the complexity, effectiveness, and clinical value of life-altering interventions that correct some congenital anomalies, ensuring they are visible in clinical data, recognized by payers, and supported for continued access and advancement in fetal care.
Q: What is the correct ICD-10-CM coding approach for poisoning cases that include documented manifestations, and how are these cases reflected in code selections and sequencing?
Heart arrhythmias are disorders of cardiac rhythm that occur when the heart’s electrical impulses do not function properly, resulting in rhythms that are too fast, too slow, or irregular. For coders, a strong understanding of arrhythmia types, applicable ICD-10-CM coding considerations, and key provider documentation requirements are needed to support accurate, compliant coding and appropriate HCC capture. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Accurate provider documentation is the foundation of compliant coding, appropriate reimbursement, and defensible claims. Yet, in a rapidly changing healthcare landscape, even highly skilled clinicians can find it difficult to stay current.
Coding purpura and thrombocytopenia is often more straightforward than coders initially expect, as these diagnoses typically require minimal direction from official guidelines. The real challenge lies in correctly interpreting provider documentation and validating the terminology used. Without close attention to clarifying terms, coders risk misclassification or unnecessary queries. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Q: What considerations should coders keep in mind when referring to problem lists for determining the principal diagnosis and proper sequencing of all documented conditions in the inpatient setting?
Trey La Charité, MD, FACP, SFHM, CCS, CCDS, discusses how without some form of a narrative in documentation, hospital coders cannot sequence individual diagnoses. If there is no story provided, records can be rife with opportunity for a recovery auditor or payer to construct an alternative version of what happened during hospital visits, resulting in denials.
Our experts answer questions on bridging the gap between DSM-5 and ICD-10 for substance-related disorders; differentiating between poisoning, adverse effects, underdosing, and toxic effects; and reporting pancreatic cancer with ICD-10-CM.
In the ever-evolving world of healthcare coding, staying grounded in the fundamentals is not just best practice, it’s a necessity. As regulations shift, payer expectations tighten, and productivity pressures mount, coding professionals must continually revisit the core principles that ensure accuracy, compliance, and integrity in clinical documentation and billing.
When a woman is pregnant, relational connections between multiple organ systems can affect both mother and fetus and thereby alter, and perhaps complicate, the care they require. In addition, determining whether a condition was pre-existing or due to the pregnancy is important but can be tricky. Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I, provides clarifications for these types of scenarios.
In the ever-evolving world of healthcare coding, staying grounded in the fundamentals is not just best practice, it’s a necessity. As regulations shift, payer expectations tighten, and productivity pressures mount, coding professionals must continually revisit the core principles that ensure accuracy, compliance, and integrity in clinical documentation and billing.
Organizations have become increasingly aware that social determinants of health play a major role in determining health disparities. With this in mind, Kelly Rice, MSHI, BSN, RN, CCDS, CDIP, CCS, CRC, reviews the changes to SDOH for FY 2026 and the response to such changes, explores strategies for continued capture of SDOH, and emphasizes the use of new SDOH ICD-10 codes available.
Failure to rescue is a compelling quality metric because it offers a lens through which healthcare organizations can illuminate, analyze, and improve the rescue zone of patient care. Teresa Brown, RN, CCDS, CCDS-O, CDIP, CCS , shows how this metric can guide meaningful improvement in patient safety and outcomes when coding and CDI professionals help use it thoughtfully.
A study published in JAMA found that people who experience a traumatic spinal cord injury are at a greater risk of developing long-term chronic conditions such as hypertension, stroke, heart disease, diabetes, and other neurological and psychiatric conditions.
Q: Why is it necessary for coders, CDI professionals, and providers to align documentation and coding for substance-related disorders when applying both the DSM-5 and ICD-10? How does this impact risk adjustment and HCC capture?
A study published in the Journal of the American College of Cardiology found that people under age 50 who consume cannabis are 6.2 times more likely to experience a heart attack than individuals who do not. It also found that they are 4.3 times more likely to experience an ischemic stroke and 2 times more likely to experience heart failure.
When a woman is pregnant, relational connections between multiple organ systems can affect both mother and fetus and thereby alter, and perhaps complicate, the care they require. In addition, determining whether a condition was pre-existing or due to the pregnancy is important but can be tricky. Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I, provides clarifications for these types of scenarios.
Asthma and chronic obstructive pulmonary disease, which encompasses emphysema and bronchitis, are two of the most prevalent and debilitating respiratory conditions. Understanding these diseases and their pathophysiology is crucial for accurate diagnosis, treatment, and coding, particularly when the conditions overlap. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Chronic conditions are among the most frequently encountered diagnoses in the outpatient setting. Accurate coding of these conditions is critical not only for proper reimbursement but also for compliance, quality reporting, and patient care continuity.
The ICD-10-CM update for 2026 included 213 new codes that incorporated the “flank” as an anatomic area related to injuries. Genetic diseases also continue to make big inroads into the tabular list of diagnoses.
Our experts answer questions about poisonings vs. adverse effects , coding neoplasm-related conditions, and office and outpatient E/M visit complexity.
Our experts answer questions on new codes introduced to differentiate multiple sclerosis subtypes, the must know concept of Elixhauser comorbidities, and key questions to address prior to coding chest pain.
Coding practices by Medicare Advantage insurers make members seem sicker, which resulted in an extra $33 billion in payments from the federal government in 2021, relative to coding by traditional Medicare providers, according to a study published by the Annals of Internal Medicine .
Cardiomyopathy refers to a group of conditions in which the heart muscle becomes diseased, making it harder for the body to pump blood effectively to the rest of the body . While accurate ICD-10-CM coding of cardiomyopathy requires precise documentation of the cause (if known) and complications, the type will drive the final code choice. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Q: In the 2026 ICD-10-CM update, in the neoplasm chapter there are some added specific codes for inflammatory neoplasm of the breast. How do those differ from other types of breast cancer?
The 2026 Medicare Physician Fee Schedule proposed rule includes significant potential changes to telehealth billing and coverage, conversion factor calculations, relative value unit weights based on site, skin substitutes, behavioral health, and more.
The ICD-10-CM update for 2026 included 213 new codes that incorporated the “flank” as an anatomic area related to injuries. Genetic diseases also continue to make big inroads into the tabular list of diagnoses.
Many disorders of immunity require ongoing management and often contribute to complications or comorbidities during hospitalization. For inpatient coders, accurately identifying and coding these disorders is crucial, not only to reflect the full clinical picture and support severity of illness and risk of mortality metrics, but also to ensure correct DRG assignment. Note : To access this free article, make sure you first register if you do not have a paid subscription.
CMS recently released an updated MLN fact sheet reminding providers when a transcatheter tricuspid valve replacement for symptomatic tricuspid regurgitation can be covered under the coverage with evidence development policy. Included are the ICD-10-CM/PCS codes that must be reported for inpatient cases.
Our experts answer questions on the proper use of the new diabetes code for cases in remission, documentation and coding solutions for denial proofing sepsis claims, and best practices for clinical validation queries.
Chronic conditions are among the most frequently encountered diagnoses in the outpatient setting. Accurate coding of these conditions is critical not only for proper reimbursement but also for compliance, quality reporting, and patient care continuity.
There are 116 new ICD-10-CM codes available for chronic non-pressure skin ulcers, added for FY 2026. Nancy Reading, BS, CPC, CPC-P, CPC-I, explores these new codes and how they were added in response to a growing problem identified as xylazine-induced skin ulcers.
Changes are being made to the ICD-10-CM conventions, general guidelines, and chapter-specific guidelines for fiscal year 2026, which will be effective October 1, 2025. This article summarizes some of the changes coders need to be aware of.
According to the National Multiple Sclerosis Society, almost one million people in the United States have been diagnosed with multiple sclerosis (MS), a chronic autoimmune neurological disorder. Discover how to code the diagnostic tests for MS, the varieties of the disorder, and treatments for it.
Like previous federal government shutdowns, the one that ensued when Congress failed to produce a continuing resolution on the budget by October 1 has implications for providers. You should reduce the chances of harm by planning to address them now.
Beginning October 1, 2025, there will be 116 new ICD-10-CM codes available for chronic non-pressure skin ulcers, added for FY 2026. Nancy Reading, BS, CPC, CPC-P, CPC-I , explores these new codes and how they were added in response to a growing problem identified as xylazine-induced skin ulcers.
Dementia is an umbrella term used to describe a group of progressive neurological disorders that affect memory, cognition, behavior, and the ability to perform everyday activities. Coding professionals must utilize diagnosis documentation, ICD-10-CM codes for both dementia and underlying physiological conditions, and coding tips to ensure that dementia-related diagnoses are captured accurately. Note : To access this free article, make sure you first register if you do not have a paid subscription.
A study published by the Journal of the American Heart Association found that ischemic heart disease death rates fell 81% from 1970 to 2022 while deaths from heart attacks decreased 89%. However, deaths from other types of heart disease increased by 81% during the same period.
Changes are being made to the ICD-10-CM conventions, general guidelines, and chapter-specific guidelines for fiscal year 2026, which will be effective October 1, 2025. This article summarizes some of the changes coders need to be aware of.
Q: The 2026 ICD-10-CM code update, effective October 1, 2025, has new codes for flank tenderness (R10.8A-) and flank pain (R10.A-). What's the difference between pain and tenderness?
Learn how HIM professionals, including coders, can leverage data related to social determinants of health to improve patient care and secure proper reimbursement.
The Agency for Healthcare Research and Quality has released the 2025 Patient Safety Indicators (PSI) updates and revisions. Review the changes in more detail and discover which outdated indicators have been removed and which indicators have been modified.
Respiratory failure is a life-threatening condition that occurs when the respiratory system is unable to maintain adequate gas exchange. Accurate coding of this condition ensures that healthcare providers can effectively communicate the severity of the condition, track patient outcomes, and avoid misclassification. Note : To access this free article, make sure you first register if you do not have a paid subscription.
It is not unusual for a professional medical coder to determine the need for multiple ICD-10-PCS procedure codes to tell the whole story about the care a patient has received during a current admission. Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I , shows how to begin by first referring to sequencing guidelines for principal and secondary ICD-10-CM diagnosis codes.
According to the National Multiple Sclerosis Society, almost one million people in the United States have been diagnosed with multiple sclerosis (MS), a chronic autoimmune neurological disorder. Discover how to code the diagnostic tests for MS, the varieties of the disorder, and treatments for it.
Our experts answer questions on better coding and CDI collaboration for escalation processes and AI implementation, queries for undocumented diagnoses and cause-and-effect relationships, and codes for hemorrhages as surgical complications.
It is not unusual for a professional medical coder to determine the need for multiple ICD-10-PCS procedure codes to tell the whole story about the care a patient has received during a current admission. Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I , shows how to begin by first referring to sequencing guidelines for principal and secondary ICD-10-CM diagnosis codes.
Our experts answer questions about diabetes mellitus in remission, percutaneous versus endoscopic discectomies, and complicated and uncomplicated problems.
While many bone fractures are often treated in emergency rooms or orthopedic clinics, certain fractures—especially severe, complex, or high-risk ones—tend to require inpatient admission. Nancy Reading, BS, CPC, CPC-P, CPC-I , shows how recognizing severity of fractures that may warrant hospitalization helps coders capture the full scope of the patient’s condition.
CMS recently released an updated MLN fact sheet reminding providers when implantable pulmonary artery pressure sensors for heart failure can be covered under the coverage with evidence development policy. Included are the ICD-10-CM/PCS codes that must be reported for inpatient cases.
Cirrhosis of the liver is categorized into distinct types that reflect different patterns of liver injury and disease progression, including hepatic fibrosis and hepatic sclerosis. Proper identification of these forms is critical for clinical accuracy and coding compliance.
With takeaways from three certified medical professionals, HIM professionals can discover how the complexity of care for major depressive disorder impacts decisions around admissions, treatment intensities, resource allocations, and service quality, beginning with outpatient care.
Because anemia is not a definitive diagnosis due to the condition having many possible causes and just as many clinical presentations, Nancy Reading, BS, CPC, CPC-P, CPC-I , visits several of the common etiologies for anemia as well as associated coding concerns.
Joanne Chopak-Foss, PhD , and Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM , look to prove how CDI professionals and coders can fully realize the value of SDOH documentation and coding in maternal and child health and shift the narrative toward equitable care for new and expecting mothers.
As the healthcare landscape evolves with new diseases, technologies, and treatment methodologies, so too must the guidelines that support the ICD-10-CM coding system. Review updates to the ICD-10-CM Official Guidelines for Coding and Reporting for fiscal year 2026 that will become effective October 1. Note : To access this free article, make sure you first register if you do not have a paid subscription.
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CMS recently published the fiscal year (FY) 2026 ICD-10-CM Official Guidelines for Coding and Reporting to accompany the ICM-10-CM update that will be effective October 1, 2025. The guidelines include clarifications and revisions to several areas that coders should note.
The second quarter edition of Coding Clinic included questions and answers for coding very specific situations not easily found using the Alphabetic Index. Review some of the noteworthy scenarios.
Physical, occupational, and speech therapy are the most common types that people think of when therapy is recommended. However, there is a new type gaining momentum: pelvic floor therapy.
Differentiating between acute kidney injury and acute tubular necrosis is particularly critical due to their implications on medical complexity and coding classification, so Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , explores the clinical foundation and diagnostic criteria of AKI and ATN, emphasizing their distinctions and significance for clinical documentation integrity and accurate ICD-10-CM coding.
Temperatures in the upper 90s and spikes into the low 100s can bring an increased risk of hospitalization for heat-related illnesses, especially in those areas which do not traditionally experience these outside intensities. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , provides guidance for reporting both diagnosis and procedure codes for sun poisoning and heatstroke admissions.
With the fiscal year (FY) 2026 ICD-10-CM update adding 487 new diagnosis codes, inpatient coders will have the opportunity to report conditions with more specificity in areas such as wound care, ophthalmology, neurology, nephrology, pathology, and chronic disease coding. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Temperatures in the upper 90s and spikes into the low 100s can bring an increased risk of hospitalization for heat-related illnesses, especially in those areas which do not traditionally experience these outside intensities. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , provides guidance for reporting both diagnosis and procedure codes for sun poisoning and heatstroke admissions.
While many bone fractures are often treated in emergency rooms or orthopedic clinics, certain fractures—especially severe, complex, or high-risk ones—tend to require inpatient admission. Nancy Reading, BS, CPC, CPC-P, CPC-I , shows how recognizing severity of fractures that may warrant hospitalization helps coders capture the full scope of the patient’s condition.
To make sure your ICD-10-CM codes are correct and complete, you may need to use an X as a placeholder to expand the code to the proper length. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The proposed 2026 Medicare physician fee schedule, released July 14, boosts the Part B conversion factor for calendar year 2026, adds billing opportunities for behavioral health services, previews new codes, and updates the agency’s quality reporting programs.
Physical, occupational, and speech therapy are the most common types that people think of when therapy is recommended. However, there is a new type gaining momentum: pelvic floor therapy.
Excluding skin cancer, breast cancer and prostate cancer are the most frequently diagnosed cancers among women and men, respectively. While both diseases originate in gender-specific organs and can range from slow-growing to aggressive forms, their clinical presentation and diagnostic complexity differ—differences that are reflected in how they are medically coded. Note : To access this free article, make sure you first register if you do not have a paid subscription.
