Understanding the clinical findings associated with quadriplegia is an important first step in determining how the condition should be reported. After reviewing the causes and effects of quadriplegia and reportable ICD-10-CM codes for the condition, this article will dive into key physical examination findings and documentation considerations that can help further guide accurate code selection. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Congenital heart defects are commonly encountered chronic conditions in pediatric coding and documentation, yet their presence alone does not ensure they are appropriately reported or fully understood within the clinical context of an encounter. Jenny Esper, RHIA, CCS, CDIP, CCDS, tackles the challenges of determining when a CHD is relevant to the admission and whether the documentation accurately reflects its clinical significance for proper coding.
With insight from Lynette Byerly, BSN, RN, CCDS, CCS, coders can discover how CDI specialists bridge the clinical world to the realm of coding and reporting, especially when pediatric conditions are not always easily reportable.
Beyond capturing primary and secondary diagnoses, what goes into a record can hugely impact how a patient is cared for both now and in the future, as well as the trajectory of a community’s health at large. See why it’s essential to go beyond surface-level knowledge and gain a true understanding of how and why SDOH data is important to track, especially for pediatric patients.
Accurate coding for liver failure requires much more than selecting the correct ICD-10-CM code—it demands an understanding of liver function, disease progression, clinical indicators, and documentation nuances. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Q: When reviewing neurologic cases, what documentation clues, imaging findings, and treatments should coders and CDI specialists look for to identify potential cerebral edema or brain compression diagnoses?
Q: When abnormal renal function is documented without a clear diagnosis, what clinical indicators should coders review to determine whether a provider query is warranted?
Human immunodeficiency virus is a chronic viral infection with clinical manifestations that can range from an asymptomatic infection to AIDS, the most advanced stage of the disease. Because HIV-related diagnoses carry unique ICD-10-CM coding guidelines, coders must carefully review the medical record to determine whether the documentation supports assignment of HIV disease, asymptomatic HIV infection, or other HIV status, as well as the presence of any HIV-related illnesses.
Q: How is artificial intelligence being used in healthcare today, and what role can AI play in improving documentation and coding workflows while still requiring human oversight?
In today’s healthcare revenue cycle, collaboration between coding teams and CDI professionals is essential for accuracy, compliance, and financial performance. At the center of this collaboration is the DRG validation auditor—a role that ensures documentation integrity and optimizes reimbursement. Jennifer Hagen, BSN, RN, CCDS, CDIP, CCS, outlines how a small hospital system transformed its CDI auditor-coder partnership into a high-impact prebill review process.
Hospitals have had a more complex time attempting to retain fair DRG payment by defending both the documented clinical diagnoses established by the treating provider and the corresponding codes in written appeal. Julie Dagen, RHIA, CCDS, CCS, seeks to address some key aspects of compliant hospital navigation through the rough waters of DRG denials.
Given the rising relevance of encephalopathy, getting a refresher on what the condition is and why it’s relevant to coding and CDI can benefit all professionals no matter their experience level. And because the clinical validation of encephalopathy is not contingent on a lab finding, but a long chain of events that require each link to be well established, organizations are still finding new ways to leverage innovative tactics in order to document it accurately.
Recovery auditors and payers have demonstrated an eagerness to exploit what providers routinely state in the medical record to facilitate additional DRG validation and medical necessity denials. Therefore, knowing what should not be said in a medical record is worth reviewing. To illustrate, Trey La Charité, MD, FACP, SFHM, CCS, CCDS, lists 10 things providers should never be documenting in the medical record.
In December 2023, the Office of the Inspector General published a toolkit for Medicare Advantage organizations who submit high-risk diagnoses, and it announced in January 2026 that an audit will be conducted on high-risk codes that the organizations submitted for 2024. Nancy Reading, BS, CPC, CPC-P, CPC-I, reviews the high-risk codes and emphasizes what to look for in the documentation to support coding practices.
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.
Coders and billers may struggle to understand what the term medical necessity really means. Unfortunately, these two words can easily lead to misinterpretation and misunderstanding of what needs to be clearly communicated in a variety of healthcare areas. Learn common definitions of medical necessity, report types utilized in inpatient settings, and a query process in case more clinical detail is required. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Insurance companies are increasingly challenging the translation from the medical record to prebill coding, making the financial impact of denials and downgrades one of the most pressing issues facing health systems today. Given the wide-ranging harm occurring from delayed and reduced reimbursement, Dawn Valdez, RN, CCDS, CDIP, highlights how coders and CDI specialists can play a key role in decreasing denials and downgrades as well as successfully disputing these actions.
Addressing the reliability of documentation, coding, and clinical reasoning underlying PSI flags is not simply a clinical safety imperative; it is a strategic business imperative. Priscilla Marlar, MHA, CSSBB, CPHQ, and John W. Cromwell, MD, suggest that achieving high reliability in quality data integrity starts with understanding the nuances of clinical documentation language and how those nuances are translated by CDI and coding teams into hospital billing codes.
