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.
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.
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.
From concussions and cerebral contusions to complex intracranial hemorrhages and traumatic brain injuries, major head injuries encompass a wide spectrum of clinical presentations and outcomes. Because of their complexity and potential for lasting impact, complete and compliant ICD-10-CM coding is essential to reflect the full clinical severity of these conditions. Note : To access this free article, make sure you first register if you do not have a paid subscription.
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.
Collaboration can take many forms depending on the needs of an organization, but Leah Ainsworth, BSHIIM, RHIA, CDIP, CCS, CCDS, shows how her department is just one of many to make coding and CDI work hand in hand to create meaningful impacts and ensure accuracy.
Q: What are the most common reasons postpartum hemorrhage is documented and coded inconsistently, and how can coders and clinicians help address these issues?
Medicare pays for physical and occupational therapy services when the medical record and the information on the claim form accurately report covered therapy services. This article discusses Medicare’s documentation requirements to justify billed therapy services. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Our experts answer questions on sorting through problem lists for the principal diagnosis, coding poisonings with resulting manifestations, and capturing loss of consciousness status.
Just as healthcare continues to evolve and change, a successful CDI program must also evolve and change. The work of the CDI team creates a positive impact in several crucial areas, including documentation accuracy and completeness, patient safety, revenue cycle, and regulatory compliance. CDI specialists play a vital role in ensuring that medical records are accurate, complete, and a reflection of the true clinical picture, which is crucial for patient safety and accurate billing.
Social determinants of health (SDOH) are critical for the well-being of the patient and are often more important than what occurs in physician’s offices, laboratories, operating rooms, and other clinical settings. Accurately capturing SDOH and providing education on doing so are equally critical for patient care, quality reporting, and reimbursement.
Q: What considerations should coders keep in mind when referring to problem lists for determining the principal diagnosis and proper sequencing of all documented conditions in the inpatient setting?
Trey La Charité, MD, FACP, SFHM, CCS, CCDS, discusses how without some form of a narrative in documentation, hospital coders cannot sequence individual diagnoses. If there is no story provided, records can be rife with opportunity for a recovery auditor or payer to construct an alternative version of what happened during hospital visits, resulting in denials.
Our experts answer questions on bridging the gap between DSM-5 and ICD-10 for substance-related disorders; differentiating between poisoning, adverse effects, underdosing, and toxic effects; and reporting pancreatic cancer with ICD-10-CM.
Artificial intelligence has revolutionized healthcare operations, offering speed and efficiency in certain tasks, but in a field where precision drives reimbursement and compliance, speed without accuracy can turn efficiency into liability. Karen R. Lane, MSN.ed, CCDS, CCDS-O, CDIP, RN, delves deep into one critical risk of using AI: hallucinations in the context of appeals.
Failure to rescue is a compelling quality metric because it offers a lens through which healthcare organizations can illuminate, analyze, and improve the rescue zone of patient care. Teresa Brown, RN, CCDS, CCDS-O, CDIP, CCS , shows how this metric can guide meaningful improvement in patient safety and outcomes when coding and CDI professionals help use it thoughtfully.
Organizations have become increasingly aware that social determinants of health play a major role in determining health disparities. With this in mind, Kelly Rice, MSHI, BSN, RN, CCDS, CDIP, CCS, CRC, reviews the changes to SDOH for FY 2026 and the response to such changes, explores strategies for continued capture of SDOH, and emphasizes the use of new SDOH ICD-10 codes available.
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?
Coders play a vital role in applying CDI technology standards by guaranteeing that the output of automated tools aligns with compliant coding practices and official coding guidelines. Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP, breaks down a framework for selecting, implementing, and maintaining technology solutions that support compliant documentation practices.
Coders and CDI specialists play a central role in accurate documentation, coding compliance, and quality metrics, yet collaboration between the two often stalls. Julie Ahlfeld, RHIT, CCS, shows how building a culture where coders and CDI professionals function as true allies can be the solution to the disconnect.
Coders play a vital role in applying CDI technology standards by guaranteeing that the output of automated tools aligns with compliant coding practices and official coding guidelines. Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP, breaks down a framework for selecting, implementing, and maintaining technology solutions that support compliant documentation practices.
As clinical validation becomes an area that payers and regulatory bodies are investigating heavily, the need for steadfast collaboration between coding professionals and CDI specialists has never been greater. TaraJo Vaught, MSN, RN, CCDS, CCDS-O, explores how these two teams can bridge the gaps between them and enhance their clinical validation practices to drive better outcomes across the board.
Join us on the podium at the 2026 Revenue Integrity Symposium (RIS), to be held September 24-25, 2026, in Savannah, Georgia. We’re now accepting proposals to speak at 2026 RIS. The deadline to apply...
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.
As clinical validation becomes an area that payers and regulatory bodies are investigating heavily, the need for steadfast collaboration between coding professionals and CDI specialists has never been greater. TaraJo Vaught, MSN, RN, CCDS, CCDS-O, explores how these two teams can bridge the gaps between them and enhance their clinical validation practices to drive better outcomes across the board.
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.
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.
CDI departments are focusing on pediatric populations through various unique initiatives, particularly with the intent to establish organizational definitions for certain diagnoses and expand clinical knowledge of intensive neonatal care. Such initiatives can support the clinical validation of reported codes and encourage good relationships with providers in case queries are needed.
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.
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.
Using her own CDI team as a case study, Yohan O. Paredes, MD, CCDS , shows how the implementation of structured CDI initiatives in pediatric and OB/GYN settings can optimize coding accuracy, regulatory compliance, and financial performance.
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.
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.
Our experts answer questions on organizing clinical validation queries, the difficulty of diagnosing skin failures, and establishing an organizational definition of sepsis.
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.
Catherine O’Leary, RN, BSN, CCDS , suggests that those who begin with manual coding and DRGs often develop a stronger, more intuitive foundation in CDI and how integrating manual training into a modern CDI program doesn’t mean abandoning technology. Her insights may prove valuable to coders who may increasingly find themselves working at the intersection of coding and CDI.
Our experts answer questions on the role of prior encounters in queries, coding neoplasms in transplanted organs, and workflows for reporting malnutrition and pathology.
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.
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.
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.
