Trey La Charité, MD, FACP, SFHM, CCS, CCDS , invites a deeper understanding for diagnosing and documenting acute renal failure and any other related diagnoses—before exploring the plethora of denial strategies medical staff may face. Not to worry as there are opportunities for successful appeals!
Q: An elderly male patient has a rectal fistula with an abscess requiring complex packing of the wound. The most recent wound documentation reports “complex persistent rectal fistula with underlying abscess present, cultures show positive for E. coli and Klebsiella.” The patient will be administered daily IV antibiotics via a PICC line that has been placed. How would this encounter be reported in ICD-10-CM?
Acute respiratory distress syndrome presents a significant clinical challenge due to its rapid onset, high mortality rate, and complex management. Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , delves into the comprehensive aspects of ARDS to show how coders, alongside healthcare providers and CDI specialists, play an essential role in reporting the complete picture of the condition.
An upcoming audit reviewing Medicare inpatient hospital billing for sepsis underscores the critical importance of accurate coding and clinical validation. With guidance from Leigh Poland, RHIA, CCS, CDIP, CIC , coders can help prevent costly coding errors, reduce the risk of audits, and ensure hospitals are appropriately reimbursed for the care they provide. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
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.
To align subcategories for diagnosis coding with the DSM-5 classification subcategories for feeding and eating disorders, new ICD-10-CM codes were added in the FY 2025 update. Nancy Reading, RN, BS, CPC, CPC-P, CPC-I , reviews the clinical criteria for affected disorders, including anorexia nervosa, bulimia nervosa, binge-eating disorder, pica in adults, and rumination disorder.
Q: Patient presents with a chief complaint of persistent cough for 10 days with occasional mucus. She has a history of chronic asthmatic bronchitis for many years; is quite frail, reporting decline in energy and activity tolerance; was a smoker until about five years ago; and suffers chronic smokers’ cough and centrilobular emphysema. Past medical history includes heart failure, hypertension, and pulmonary hypertension. How would this diagnostic note be reported in ICD-10-CM?
Certain diagnosis-related groups (DRGs) remain vulnerable to audits and denials, not only for DRG and clinical validation, but for medical necessity as well. Kim Conner, BSN, CCDS, CCDS-O , explores areas coding professionals can support when being proactive against these denials.
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.
Q: A 65-year-old female has been on Effexor for major depressive disorder for three months and went to her healthcare provider due to tachycardia and palpitations along with mild muscle cramping. It was found that she had accidentally been taking double her prescribed dose due to misunderstanding the instructions. It is reported that she developed serotonin syndrome resulting from toxicity and was also diagnosed with mild hypertension (138/88) due to the serotonin syndrome. How would this encounter be reported in ICD-10-CM?
Lymphoma diagnosis codes received a robust overhaul with the release of the 2025 ICD-10-CM codes, reflecting advancements in understanding and classifying lymphoma. Accurate coding is crucial for reporting such nuances, and Nancy Reading, RN, BS, CPC, CPC-P, CPC-I , is here to update coders on the changes.
Coagulopathy describes the impairment of the blood’s ability to coagulate, leading to prolonged or excessive bleeding that may occur spontaneously or following an injury. Explore the basics of the condition as well as practical tips for accurate ICD-10 coding. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Coding professionals face challenges when the clinical meanings of words do not match the ICD-10-CM classification system, particularly for records related to matters of the heart. Follow Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , as she applies critical thinking, knowledge of disease processes, and an understanding of ICD-10-CM codes to accurately report acute MI cases.
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.
Certain diagnosis-related groups (DRG) remain vulnerable to audits and denials, not only for DRG and clinical validation, but for medical necessity as well. Kim Conner, BSN, CCDS, CCDS-O , explores areas coding professionals can support when being proactive against these denials.
Our experts answer questions on the new ICD-10-CM serotonin syndrome code, key takeaways for documenting and supporting malnutrition diagnoses, and appropriate circumstances for reporting codes from ICD-10-CM subcategory E66.8- (other obesity).
Our experts answer questions about serotonin syndrome, the difference between National Correct Coding Initiative edits and medically unlikely edits, and prolonged service codes.
