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.
Operative reports often contain more precise and detailed information than preoperative notes or consent forms, and correctly interpreting those details is essential to assigning the right inpatient procedure codes. Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP, provides coders with actionable strategies for reviewing surgical documentation and applying codes.
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.
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?
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.
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.
ICD-10-CM codes for Parkinson’s disease differ based on the primary neurologic diagnosis and any complications or comorbidities involved, as PD can manifest in various forms, each with unique characteristics.
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.
Social issues often get left out of the conversation when providers, caregivers, and patients are busy, stressed, and focused on the immediate problem that occasioned a visit or admission; however, Nicole Nodal-Rodriguez, MSN, RN, CCDS , considers how having SDOH carried through the record can have a trickledown effect on treatment plans, identification of health disparities, and community services.
The ICD-10-CM classifies deep vein thrombosis with a high degree of specificity based on severity, affected extremity, vein location, and laterality, but without detailed clinical documentation or consistent terminology use, coders may need to query providers often for clarification in order to assign the right code.
Jenny Esper, RHIA, CDIP, CCS, CCDS , and Lizabeth Volansky, BSN, RN, CCDS, RHIA, CDIP, CCS , explore the topic of including references or links to definitions within query notes and how such a practice can enhance documentation and coding.
Psychosis often emerges or is managed in outpatient mental health settings, but it can be coded during inpatient hospital stays due to the acute nature of the condition when it reaches a crisis point. To ensure that this mental health diagnosis receives the same diligence as medical and surgical diagnoses, Nancy Reading, RN, BS, CPC, CPC-P, CPC-I , provides coders with guidance on finding the right codes and resolving documentation conundrums.
CMS recently issued a bulletin highlighting new Medicare documentation guidelines and providing additional resources for documentation compliance. Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS , outlines the key takeaways from this latest guidance and emphasizes how health information, CDI, and coding teams play a role in compliant documentation.
Coders play a crucial role in addressing clinical and coding denials, but they are far from alone in this effort. All HIM professionals are working together to create and implement comprehensive strategies that effectively reduce denials, fostering a unified approach to overcoming these challenges.
