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.

With guidance from Linda Martien, CPC, COC, CPMA, CPC-I, CRC, AAPC approved instructor, AAPC fellow , coding professionals can review arthritis codes to avoid the use of generalized codes in order to reflect a patient’s condition more accurately and ensure compliance with insurance requirements.

Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, provides an overview of toxic encephalopathy including signs and symptoms, diagnosis and treatment, and relevance for coding professionals and CDI teams.

Malnutrition affects millions of people across all age groups, and to better discuss and understand the coding nuances of malnutrition, Cokethia Rachel, CPC, CCS, CPMA, SSBBP, demonstrates how coders should define the condition, appropriately review relevant documentation, and recognize when the medical necessity of malnutrition has been supported. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Sepsis is one of the most prevalent diagnoses necessitating hospital admissions in the United States, and unfortunately, sepsis denials are also prevalent and on the rise. John Williams, RN, BSN, CCDS, clarifies how to ensure all indicators and findings of sepsis are present and valid for each inpatient admission.

Medical decision-making (MDM) documentation has gained increased importance in recent years to justify a visit’s medical necessity. Review CMS’ MDM table and guidelines to take the guesswork out of your coding.

Nancy Reading, RN, CPC, CPC-P, reviews the Phoenix Sepsis Score, a new set of clinical parameters to define and diagnose pediatric sepsis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Nancy Reading, RN, CPC, CPC-P, reviews the Phoenix Sepsis Score, a new set of clinical parameters to define and diagnose pediatric sepsis.

Sarah McDonald, CPC, explains the spinal fusion process and overviews the process of constructing ICD-10-PCS procedure codes character by character.

Teresa Seville, RHIT, CCS, explains that a thorough review of ICD-10 updates must include analysis of the addenda, including the index, tabular notes, guidelines, and committee meeting highlights.

For accurate CPT and ICD-10-CM coding of fractures, coders will need to identify many pieces of information, including location and type. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Amanda Vincent, MBA, CCS, CPC, CCDS, CRC, explains the differing definitions of “complication” for providers vs. coders, reviews types of complications, and codes an intraoperative laceration case study.

Spinal surgery for hospital coders can be very challenging if they do not know the rules for assigning the correct ICD-10-PCS codes. Nancy Reading, RN, CPC, CPC-P , reviews spinal anatomy and surgical approaches, and offers tips on how to select the most appropriate characters in ICD-10-PCS.

Kate Siemens, RN, CMSRN, CCDS , discusses the clinical indicators for malnutrition during end-of-life care with Taylor Kuykendall, MS, RD, LD . She covers relevant ICD-10-CM codes and proper reporting methodologies for the condition.

Despite sepsis being the leading cause of hospital readmissions and in-hospital deaths in the U.S., its extensive history of clinical definitions and criteria can cause confusion for even the most experienced coders.

The 2024 ICD-10-CM update brings almost 400 code changes, including new codes for sickle-cell retinopathy and orbital muscle entrapment. This article delves into the causes, symptoms, and reporting methods for these two ocular conditions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Hemodialysis involves diverting blood into an external machine, where it is filtered and returned to the body. Sarah Gould, CPC , describes the vascular surgical options for hemodialysis (fistulas and grafts), their various types, and how to report them in ICD-10-PCS. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Shelley Safian, PhD, RHIA, CCS-P, COC, CPC-I, defines hand-assisted laparoscopic surgery (HALS) procedures and how to report them according to new guidance in the 2024 ICD-10-PCS guidelines. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

ICD-10-PCS provides many codes related to respiratory assistance, ECMO, and ultrasound for procedures for newborns/neonates. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , reviews these procedures and offers clinical coding scenarios to clear up confusion. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Shelley Safian, PhD, RHIA, CCS-P, COC, CPC-I, defines hand-assisted laparoscopic surgery (HALS) procedures and how to report them according to new guidance in the 2024 ICD-10-PCS guidelines.

Coders saw extensive code changes and expansion for ICD-10-CM category O35.- in 2023. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG, reviews codes in Chapter 15, section E: Fetal conditions affecting the management of the mother.

This article reviews the most common types of external diagnostic cardiology tests, examines relevant CPT coding guidelines, and offers reporting advice from an expert.

Spinal fusions can effectively eliminate pain and restore stability to the spine. Learn how to apply ICD-10-PCS codes and guidelines for spinal fusions and related procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Pneumonia is the eighth-leading cause of death in the U.S. This article outlines signs and symptoms of respiratory infection, pneumonia etiologies, and ICD-10-CM coding for complex pneumonia. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Atrial fibrillation is the most common type of cardiac rhythm disorder in the U.S. This article defines the condition, reviews relevant ICD-10-CM coding guidelines, and provides documentation and reporting guidance from experts. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Approximately 1.7 million adults in America develop sepsis each year, according to the Centers for Disease Control and Prevention. Review documentation requirements and ICD-10-CM coding for severe sepsis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Q: A surgeon performed an arthroscopic biceps tenotomy on a patient, but I cannot find a CPT code for it. How would I report it?

When reporting ICD-10-CM codes for encephalopathy with comorbidities, coders must carefully review documentation to determine which conditions are separately reportable. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG , breaks down ICD-10-CM reporting guidance for complex cases of encephalopathy.

Functional and structural disorders, infections, and irritations of the large intestine can cause debilitating digestive complications that require surgical intervention. Review ICD-10-PCS coding for colectomy and ostomy procedures.

Cerebrovascular accidents (CVA) are the fifth-leading cause of death and a leading cause of disability in the U.S., according to the Centers for Disease Control and Prevention. Review ICD-10-CM coding for CVA and ICD-10-PCS coding for surgical interventions used to open blocked arteries. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Findings from a recent medical record review published by JAMA Network Open show that physical assaults are often miscoded as accidents. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , breaks down ICD-10-CM coding for specific details about an injury or health event.

Encephalopathy refers to any disease of the brain that alters its function or structure. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG , breaks down documentation requirements and ICD-10-CM coding for toxic, acute, and chronic encephalopathy.

Adhere to ICD-10-PCS guidance for reporting multiple procedures and procedural components when coding for wound debridement and skin grafting. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

This article outlines when and how to report new and revised 2023 CPT codes for arthroplasty and arthrodesis procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Coding and CDI professionals should understand disease processes for common inpatient diagnoses. Ronald Singell, RN, BSN, CCDS , writes about clinical indicators of disease for diabetic ketoacidosis, gastrointestinal hemorrhage, and sequential organ failure.

The American Medical Association's update to the 2023 CPT code set has brought three code additions, one revision, and one deletion to the integumentary chapter (CPT codes 10030-19499). This article provides procedure descriptions and coding guidance for the new and revised codes. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

If a urinary tract infection is left untreated, it can spread to other organs and cause sepsis and septic shock. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , breaks down ICD-10-CM coding for this life-threatening diagnosis.

The 2023 CPT code update introduced numerous code additions, revisions, and deletions that took effect January 1. This article covers new and revised codes in the respiratory and nervous system chapters of the CPT Manual. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

While laser interstitial thermal therapy (LITT) is not new, the expansion of its use for diagnoses beyond brain tumors can help a new patient population. Shelley C. Safian, PhD, RHIA, HCISPP, CCS-P, COC, CPC-I , describes how LITT is documented and reported in ICD-10-PCS.

The American Medical Association recently published CPT codes for 2023, including 103 code additions, 88 revisions, and 69 deletions. This article covers new codes and the single revision made to the cardiovascular system chapter. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Cardiorenal syndrome refers to acute or chronic dysfunction of the heart or kidneys that causes dysfunction in the other organ. Review ICD-CM coding for heart and kidney failure and the physiological impact that dysfunction in one system has on the rest of the body. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Coding for newborn services can be complicated due to detailed examinations and therapeutic treatments performed after delivery. Sarah Nehring, RHIA, CCS, CCDS , breaks down ICD-10-CM coding for newborn encounters and reviews new codes for newborn apnea that took effect October 1.

Stroke, or cerebrovascular accident (CVA), is the fifth leading cause of death in the U.S. and the second leading cause of death worldwide, according to the Centers for Disease Control and Prevention. Unpack clinical documentation and ICD-10-CM coding for various types of CVA. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Coders must be familiar with ICD-10-CM reporting guidelines for common neurological conditions. This article unpacks recent updates to the nervous system chapter of ICD-10-CM including 14 new codes for autonomic conditions and fatigue syndromes. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Q: How do CPT codes 28295 (correction, hallux valgus, with sesamoidectomy, when performed; with proximal metatarsal osteotomy, any method) and 28298 (…; with proximal phalanx osteotomy, any method) differ?

Erectile dysfunction, sometimes called impotence, is a common male disorder. Debbie Jones, CPC, CCA covers physiology, symptoms, and treatment for erectile dysfunction, as well as associated ICD-10-CM and CPT codes.

Arthroscopic procedures have been the topic of controversy and confusion in the coding community. This article covers relevant anatomy, common shoulder arthroscopy and arthroplasty procedures, and National Correct Coding Initiative edits to keep in mind. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

Interventional radiology describes a set of procedures that involve the insertion of medical devices and instruments to diagnose or treat disorders of blood vessels. This article covers common revascularization procedures, CPT codes associated with each vascular territory, and potential coding errors. Note : To access this free article, make sure you first register here if you do not have a paid subscription.

A broken nose is a break in the bone or cartilage over the bridge of the nose or over the septum—the structure that separates the nostrils. Debbie Jones, CPC, CCA , explains how to select the most specific CPT codes for nasal fracture and dislocation treatments.