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?
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?
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.
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?
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.
Our experts answer questions about diabetes mellitus in remission, percutaneous versus endoscopic discectomies, and complicated and uncomplicated problems.
Q: When a diagnosis is clinically evident but not yet documented or there is uncertainty about a cause-and-effect relationship between related conditions, would queries be outlined similarly to other types of queries or include different information?
Q: Are there solutions for having better coding and CDI collaboration? How might this help teams with escalation processes and implementation of AI programs?
Our experts answer questions about independent historians, the number and complexity of problems addressed at an encounter, and counting discussion of management.
Q: What if a provider sends a summary of their visit with a patient to the patient’s primary care provider. Is this considered a “discussion” of patient management?
Q: What’s the difference between CPT code 90791 (Psychiatric diagnostic evaluation) and 90792 (Psychiatric diagnostic evaluation with medical services)?
Our experts answer questions on organizing clinical validation queries, the difficulty of diagnosing skin failures, and establishing an organizational definition of sepsis.
Our experts answer questions about medical decision-making, locating procedure codes, and coding a revision of a unicompartmental knee arthroplasty to a total knee arthroplasty.
Our experts answer questions on the role of prior encounters in queries, coding neoplasms in transplanted organs, and workflows for reporting malnutrition and pathology.
Our experts answer questions about the standard of care, reporting reduced services, and problems addressed during evaluation and management office visit.
Our experts answer questions on NICU coding, ICD-10-CM coding for kidney transplants with kidney failure or other complications, and the acceptance of systemwide clinical definitions on queries.
Our experts answer questions about assigning modifiers, mental health documentation and assigning evaluation and management service levels based on time.
Our experts answer questions on overcoming documentation challenges for sepsis, ICD-10-CM coding for infections of devices vs. wound infections as well as class three obesity and/or morbid obesity, and querying physician abbreviations.
Q: A month ago, a patient had undergone an open reduction and internal fixation of a traumatic fracture of the left femur. This afternoon, she was admitted for a severe and deep infection of the left thigh and immediately taken to surgery. An open, wide excisional debridement of the infected skin, subcutaneous tissue, and fascia was carried out, and the internal fixation hardware was removed. Cultures of the fixation pins grew Staphylococcus aureus. Can coders report infections of devices similar to how they would report a wound infection in ICD-10-CM?
Q: Consider a patient who received a hysterectomy two days ago and was later admitted for severe acute abdominal pain around the surgical wound. When the wound was reopened, it was discovered that an instrument had been left in her body. The instrument was removed, and the wound was resutured. How would coders report this situation with ICD-10-CM codes?
