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?
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.
In our upcoming ACDIS & JustCoding virtual seminar, James F. Salter IV, CCS, will spend time breaking down the complexities of liver failure coding, helping attendees understand how acuity drives code assignment, distinguish between similar hepatic conditions, and recognize valuable documentation and query opportunities. As a preview of what you'll learn during the session, here's a glimpse into some of the introductory concepts that will be explored. Note : To access this free article, make sure you first register if you do not have a paid subscription.
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.
Our experts answer questions on assigning ICD-10-CM P codes versus Z codes for newborn conditions, using artificial intelligence to improve documentation and coding workflows, and coding postsurgical malabsorption.
Hospitals are seeing an increasing number of clinical validation denials that are frequently linked to documentation that does not fully describe the clinical severity of the patient’s condition, even though the documentation technically meets coding requirements. One helpful way to approach this issue is by recognizing inpatient severity drivers—such as physiological instability, organ dysfunction, and treatment intensity—in order to understand the true severity of illness in hospitalized patients.
In a world full of denials, sometimes the best thing you can be is a denials specialist. However, only 11.66% of respondents to the 2025 ACDIS CDI Salary Survey reported that their department included a CDI denials specialist role.
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.
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?
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.
Six healthcare information management professionals review an initiative at their organization that has provided a structured and sustainable approach to improving the documentation of encephalopathy and offers a replicable framework for addressing documentation challenges of other clinical conditions that are often characterized by diagnostic ambiguity. Such efforts can help ensure appropriate representations of patient acuity, accurate coding practices, sufficient risk-adjustment modeling, and decreased retrospective query burden.
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.
In an effort to streamline the query process and ensure each missive adheres to stringent compliance standards, many programs now rely on templates that coding and CDI professionals can customize for the specific query opportunity at hand. To explore this topic further, ACDIS asked members of the 2025/2026 CDI Leadership Council to share their thoughts on query templates.
The phrase “don’t reinvent the wheel” applies well to the development of an outpatient CDI program when a mature inpatient CDI foundation already exists. The challenge is not whether the wheel can be reused, but how to navigate the differences.
CMS is signaling a clear shift in how it views risk adjustment, quality performance, and documentation integrity. For coding and CDI professionals, this moment represents not a threat, but a critical inflection point.
The phrase “don’t reinvent the wheel” applies well to the development of an outpatient CDI program when a mature inpatient CDI foundation already exists. The challenge is not whether the wheel can be reused, but how to navigate the differences.
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.
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.
