Social determinants of health ICD-10-CM codes have become more of a hot topic in the CDI world over the past few years. Review guidance for reporting personal circumstances such as income, wealth, and education that impact health and wellbeing.
Pregnancy causes changes to the immune system that increase the risk of infection and sepsis during pregnancy, labor, and the puerperium. Sarah Nehring, BS, RHIT, CCS, CCDS , analyzes ICD-10-CM documentation and coding for sepsis after childbirth.
A properly calibrated audit tool is key to uncovering educational opportunities for coding and CDI professionals. Dawn Valdez, RN, LNC, CDIP, CCDS, outlines questions for determining an audit focus and for querying providers when documentation is insufficient to support medical necessity.
Respiratory failure occurs when the body is unable to provide oxygen to or remove carbon dioxide from the body. Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , breaks down documentation and ICD-10-CM coding for acute and chronic respiratory failure.
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.
Many healthcare systems are looking at how to expand their CDI program to include outpatient and ambulatory settings. Jennifer Boles, BS, COC, CRC, CCDS-O, explores her ambulatory CDI program’s success and offers advice for those looking to expand.
Audits are crucial to helping CDI and coding teams stay up to date with the fast pace of medicine and continual changes to coding guidelines. Dawn Valdez, RN, LNC, CDIP, CCDS , writes about best practices for auditing and application of audit findings .
Many healthcare systems are looking at how to expand their CDI program to include outpatient and ambulatory settings. Jennifer Boles, BS, COC, CRC, CCDS-O, explores her ambulatory CDI program’s success and offers advice for those looking to expand.
Social determinants of health such as economic stability and access to education significantly impacting health outcomes. Kim Conner, BSN, RN, CCDS, CCDS-O , outlines potentially confusing ICD-10-CM guidelines and documentation challenges that complicate coding for social determinants.
Debridement is used to treat serious or chronic wounds that do not heal with standard treatment. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG , describes five types of debridement and how to report these procedures in ICD-10-PCS.
Social determinants of health such as economic stability and access to education significantly impacting health outcomes. Kim Conner, BSN, RN, CCDS, CCDS-O , outlines potentially confusing ICD-10-CM guidelines and documentation challenges that complicate coding for social determinants.
Coders must be familiar with updates to the ICD-10-CM/PCS code sets for fiscal year 2023 . Audrey Howard, RHIA , reviews new codes and reporting guidelines for dementia, care complications, and vascular procedures as well as updates to MS-DRGs.
Malnutrition includes undernutrition, inadequate vitamins or minerals, overnutrition, obesity, and diet-related noncommunicable diseases. Inpatient coders must be familiar with clinical criteria and ICD-10-CM coding for this condition as it is frequently the focus of clinical validation audits. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Inpatient coders have malnutrition on their mental list of diagnoses at risk of audits. Learn how to effectively work with dieticians and CDI staff to ensure accurate documentation and ICD-10-CM coding for malnutrition.
Reconciling CDI reviews and queries against final coding is an important but sometimes overlooked step. Use these expert tips to refresh or develop your organization's CDI and coding reconciliation process.
Sepsis and systemic inflammatory response syndrome are historically difficult to document and report in ICD-10-CM. Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , breaks down sepsis definitions and outlines a process for query creation.
Hospital coders must be able to determine the reason for an admission and to differentiate conditions present on admission (POA) from those that develop during an inpatient stay. Learn how to effectively decipher documentation to identify the principal diagnosis and conditions that were POA.
