An upcoming audit reviewing Medicare inpatient hospital billing for sepsis underscores the critical importance of accurate coding and clinical validation. With guidance from Leigh Poland, RHIA, CCS, CDIP, CIC , coders can help prevent costly coding errors, reduce the risk of audits, and ensure hospitals are appropriately reimbursed for the care they provide. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS , invites a deeper understanding for diagnosing and documenting acute renal failure and any other related diagnoses—before exploring the plethora of denial strategies medical staff may face. Not to worry as there are opportunities for successful appeals!
Q: An elderly male patient has a rectal fistula with an abscess requiring complex packing of the wound. The most recent wound documentation reports “complex persistent rectal fistula with underlying abscess present, cultures show positive for E. coli and Klebsiella.” The patient will be administered daily IV antibiotics via a PICC line that has been placed. How would this encounter be reported in ICD-10-CM?
Acute respiratory distress syndrome presents a significant clinical challenge due to its rapid onset, high mortality rate, and complex management. Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , delves into the comprehensive aspects of ARDS to show how coders, alongside healthcare providers and CDI specialists, play an essential role in reporting the complete picture of the condition.
A new separate payment is available under the FY 2025 IPPS for small, independent hospitals who choose to establish and maintain access to buffer stocks of essential medicines. Learn why this initiative was created and the potential impacts on future drug shortages.
Coding professionals are critical to the compliance initiatives of any healthcare organization, and the application of codes to a claim ignites the compliance ember. Discover how key initiatives not only ensure coders act ethically and responsibly but also enhance the accuracy of coding. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
To align subcategories for diagnosis coding with the DSM-5 classification subcategories for feeding and eating disorders, new ICD-10-CM codes were added in the FY 2025 update. Nancy Reading, RN, BS, CPC, CPC-P, CPC-I , reviews the clinical criteria for affected disorders, including anorexia nervosa, bulimia nervosa, binge-eating disorder, pica in adults, and rumination disorder.
With guidance from three certified medical professionals, CDI specialists and coders can learn how to fight against the overwhelming tide of clinical validation denials by promoting strong documentation, capturing clinical pictures with appropriate codes, and justifying treatment plans.
Q: Patient presents with a chief complaint of persistent cough for 10 days with occasional mucus. She has a history of chronic asthmatic bronchitis for many years; is quite frail, reporting decline in energy and activity tolerance; was a smoker until about five years ago; and suffers chronic smokers’ cough and centrilobular emphysema. Past medical history includes heart failure, hypertension, and pulmonary hypertension. How would this diagnostic note be reported in ICD-10-CM?
Review a recent OIG audit which found that Medicare payments for inpatient claims assigned with MS-DRGs 207 and 870 did not fully comply with Medicare requirements, resulting in $79.4 million being improperly paid to hospitals.
CMS implemented the FY 2025 IPPS final rule on October 1, which introduced several updates to New Technology Add-on Payment designations, directly affecting how inpatient services are coded and reimbursed. Follow Judith Kares, JD , as she reviews NTAP eligibility criteria and payment strategies, alternative pathways for approval, final new technologies, and application process changes. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Review a retrospective cohort study published in the Journal of the American Medical Association that found new Alzheimer disease and related dementia diagnoses were more common after falls compared with other forms of traumatic injury.
Denials continue to be a pain point and significant challenge for every hospital across the nation, but Angelica Cage, MBA, BSN, RN, CCDS, CCS, CDIP , provides denial-proofed queries to show how establishing a diagnosis that is strongly supported by the available clinical evidence can reduce or eliminate clinical doubt with respect to the treated condition.
Certain diagnosis-related groups (DRGs) remain vulnerable to audits and denials, not only for DRG and clinical validation, but for medical necessity as well. Kim Conner, BSN, CCDS, CCDS-O , explores areas coding professionals can support when being proactive against these denials.
Lymphoma diagnosis codes received a robust overhaul with the release of the 2025 ICD-10-CM codes, reflecting advancements in understanding and classifying lymphoma. Accurate coding is crucial for reporting such nuances, and Nancy Reading, RN, BS, CPC, CPC-P, CPC-I , is here to update coders on the changes.
Coding professionals face challenges when the clinical meanings of words do not match the ICD-10-CM classification system, particularly for records related to matters of the heart. Follow Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , as she applies critical thinking, knowledge of disease processes, and an understanding of ICD-10-CM codes to accurately report acute MI cases.
Coagulopathy describes the impairment of the blood’s ability to coagulate, leading to prolonged or excessive bleeding that may occur spontaneously or following an injury. Explore the basics of the condition as well as practical tips for accurate ICD-10 coding. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: A 65-year-old female has been on Effexor for major depressive disorder for three months and went to her healthcare provider due to tachycardia and palpitations along with mild muscle cramping. It was found that she had accidentally been taking double her prescribed dose due to misunderstanding the instructions. It is reported that she developed serotonin syndrome resulting from toxicity and was also diagnosed with mild hypertension (138/88) due to the serotonin syndrome. How would this encounter be reported in ICD-10-CM?
To comply with a summer court order, the FY 2025 Hospital Inpatient Prospective Payment System was revised to reduce payments for low wage hospitals. Review the updated policy to understand why these adjustments were implemented and what hospitals can expect going forward.
The majority of U.S. healthcare organizations struggle with denials and underpayments in all care settings, making it difficult to keep up with a meaningful manual appeals process. Learn how coding professionals can leverage technology to accurately capture and validate clinical data, ensuring proper coding and documentation while reducing the likelihood of denials. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: A patient presents with exacerbation of COPD complicated by positive COVID-19 with COVID-19 pneumonia and superimposed MRSA bacterial pneumonia in the setting of chronic bronchitis due to smoking, severe persistent asthma (not currently in exacerbation), and left lower lobe lung cancer in remission following a lobectomy one year ago. Patient continues to smoke cigarettes. How would this diagnostic note be reported in ICD-10-CM?
Successfully managing inpatient stay denials should begin long before they occur and depends on having excellent case management, CDI, and coding departments. Although these departments have differing duties, Cathy Farraher Nakhoul, RN, BSN, MBA, CCM, CCDS , shows how they all play a part in ensuring that the final coded data is compliant and accurate.
Review a cross-sectional study published in the Journal of the American Medical Association that revealed people experiencing homelessness were significantly less likely to receive inpatient systemic therapy or procedures despite having a higher prevalence of more aggressive cancers and longer lengths of stay.
With guidance from Linda Martien, CPC, COC, CPMA, CPC-I, CRC, AAPC approved instructor, AAPC fellow , coding professionals can review arthritis codes to avoid the use of generalized codes in order to reflect a patient’s condition more accurately and ensure compliance with insurance requirements.
Review a recent OIG audit which found that without strengthening program safeguards, CMS and its contractors may not be able to prevent or detect improper payments for short inpatient stays or recover overpayments for claims that do not comply with Medicare requirements.
Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, provides an overview of toxic encephalopathy including signs and symptoms, diagnosis and treatment, and relevance for coding professionals and CDI teams.
Q: Consider patients who are admitted with cellulitis and have type 2 diabetes mellitus with no neuropathy or elevated glucose levels. Should coders query the provider to clarify if the cellulitis is caused by the diabetes, or should such a query only be sent if a patient has other complications of diabetes such as hypoglycemia or neuropathy?
With advice from three certified medical professionals, CDI specialists and healthcare providers can develop relationships that foster a culture of collaboration and continuous improvement in documentation and coding practices.
Pancytopenia is defined as the simultaneous presence of anemia, leukopenia (neutropenia), and thrombocytopenia. Refresh yourself on how each condition plays a role in diagnosing, treating, and coding pancytopenia. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: Video colonoscope was advanced through a patient’s rectum to the cecum where there was normal-looking mucosa throughout. The patient had scattered diverticula in the sigmoid colon and a 6-mm sessile polyp in the proximal rectum that was removed completely by hot biopsy technique. Surgeon documented to await pathology report. How would this operative note be reported in ICD-10-CM and ICD-10-PCS?
Malnutrition affects millions of people across all age groups, and to better discuss and understand the coding nuances of malnutrition, Cokethia Rachel, CPC, CCS, CPMA, SSBBP, demonstrates how coders should define the condition, appropriately review relevant documentation, and recognize when the medical necessity of malnutrition has been supported. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP, explores common reasons for sepsis-related denials, offers strategies for effective documentation and coding, and presents approaches to successfully appeal these denials.
A cohort study published in the Journal of the American Medical Association found that the detection of incident stroke events is moderately accurate when using ICD-10-CM codes in Medicare claims and very accurate in ruling out non-stroke cases.
CMS released the FY 2025 IPPS final rule on August 1, which seeks to address key social determinants of health and strengthen emergency preparedness. This rule updates Medicare payments and policies for discharges from inpatient hospitals beginning October 1, 2024.
Q: A patient is in the postpartum period after delivering a healthy baby girl. She developed diabetes mellitus during the pregnancy. She is being treated with Metformin, an oral hypoglycemic drug. How would this situation be reported in ICD-10-CM?
Chronic conditions pose significant challenges to individuals and healthcare systems alike, often leading to reduced quality of life, increased healthcare costs, and rise in mortality rates if left unmanaged. Proper documentation of chronic conditions, however, can help facilitate communication, coordination, and continuity of care for patients from healthcare providers. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Teresa Brown, RN, CCDS, CDIP, CCS, explores the significance of the Elixhauser Comorbidity Index in enhancing our understanding of patient health profiles and supporting informed decision-making across various facets of healthcare delivery.
Amid the myriad of conditions and diseases, probable catheter-associated bloodstream infections emerge as a focal point for clinical intervention and revenue cycle efficiency. Pooja Patwal, MBBS(MD), CCS, CDIP, CHCQM , explores how capturing accurate ICD-10 codes for probable BSIs is paramount for healthcare facilities striving for excellence in patient outcomes.
Q: A physician documented metabolic encephalopathy on a postoperative patient who was sedated on a vent, but because there were not documented responses while on the vent, I was unable to clinically validate the encephalopathy while the patient was sedated on the vent. How would a coder query this diagnosis for validity?
Sepsis is one of the most prevalent diagnoses necessitating hospital admissions in the United States, and unfortunately, sepsis denials are also prevalent and on the rise. John Williams, RN, BSN, CCDS, clarifies how to ensure all indicators and findings of sepsis are present and valid for each inpatient admission.
The new ICD-10-PCS code set for fiscal year 2025, which includes 371 new codes, will be effective October 1, 2024. With highlights from Terry Tropin, MSHAI, RHIA, CCS-P , inpatient coders can make sense of each new term before they go into effect.
CMS’ fiscal year 2025 IPPS proposed rule and fact sheet proposes to upgrade certain codes describing social determinants of health (SDOH) to better capture the effect of housing instability on beneficiaries.
HIPAA has protocols for when patients’ protected health information can be used for research and marketing. This means you must understand privacy rule limitations and your organization’s policies and procedures before releasing any PHI in these situations. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Without proof that services rendered were medically necessary, third-party payers are unlikely to approve claims for reimbursement. With tips from Shelley C. Safian, PhD, RHIA, CCS-P, COC, COC-I , medical coding professionals can use ICD-10-CM codes to prove medical necessity. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Most facilities find acute respiratory failure to be a commonly denied diagnosis. Sharme Brodie, RN, CCDS, CCDS-O, explores when the circumstances of admission and the focus of care support the condition for coding.
The best technical security in the world cannot prevent breaches of protected health information if people are careless. Coders, billers, and HIM professionals should then learn to protect confidential health information by following proper security procedures and creating effective passwords.
A study published in the Journal of the American Medical Association found that administration of piperacillin-tazobactam among patients with suspected sepsis was associated with a higher mortality rate and increased duration of organ dysfunction compared with cefepime administration.
Q: A patient presents with a chief complaint of thoracic intrinsic spinal cord lesion causing back pain, left lower extremity sciatic-type pain, and foot drop. An MRI of the thoracic spine revealed a T11-T12 spinal cord lesion consistent with a cavernous malformation. Which ICD-10-CM codes would be reported?
