Heart arrhythmias are disorders of cardiac rhythm that occur when the heart’s electrical impulses do not function properly, resulting in rhythms that are too fast, too slow, or irregular. For coders, a strong understanding of arrhythmia types, applicable ICD-10-CM coding considerations, and key provider documentation requirements are needed to support accurate, compliant coding and appropriate HCC capture. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Coding for spinal fusions is very confusing, with many different devices and approach options as well as the procedure requiring more than one code. Terry Tropin, MSHAI, RHIA, CCS-P, walks through the Medical and Surgical section of the ICD-10-PCS to find where appropriate spinal fusion codes can be located.
Q: What is the correct ICD-10-CM coding approach for poisoning cases that include documented manifestations, and how are these cases reflected in code selections and sequencing?
The American Hospital Association recently released a report that found patient safety in hospitals and health systems across the nation has continued to improve. It also found that despite caring for a sicker patient population, the focus on safety has led to improved patient outcomes and reduced infections.
Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I, shows how reporting perinatology procedures with ICD-10-PCS is essential to accurately reflect the complexity, effectiveness, and clinical value of life-altering interventions that correct some congenital anomalies, ensuring they are visible in clinical data, recognized by payers, and supported for continued access and advancement in fetal care.
Review a recent OIG audit which found that Medicare improperly paid $22.7 million to suppliers for durable medical equipment, prosthetics, orthotics, and supplies during inpatient stays from January 2018 to December 2024.
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.
Transcatheter aortic valve replacement is a minimally invasive procedure developed to treat patients with severe aortic stenosis who are considered high-risk or unsuitable candidates for traditional open-heart surgery. Learn from Jane Arbogast-Schappell, CCS, CPC, CCC, CIRCC, as she walks through the procedural coding for both inpatient and outpatient settings.
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?
Coding purpura and thrombocytopenia is often more straightforward than coders initially expect, as these diagnoses typically require minimal direction from official guidelines. The real challenge lies in correctly interpreting provider documentation and validating the terminology used. Without close attention to clarifying terms, coders risk misclassification or unnecessary queries. Note : To access this free article, make sure you first register if you do not have a paid subscription.
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.
When a woman is pregnant, relational connections between multiple organ systems can affect both mother and fetus and thereby alter, and perhaps complicate, the care they require. In addition, determining whether a condition was pre-existing or due to the pregnancy is important but can be tricky. Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I, provides clarifications for these types of scenarios.
Transcatheter aortic valve replacement is a minimally invasive procedure developed to treat patients with severe aortic stenosis who are considered high-risk or unsuitable candidates for traditional open-heart surgery. Learn from Jane Arbogast-Schappell, CCS, CPC, CCC, CIRCC, as she walks through the procedural coding for both inpatient and outpatient settings.
Laurie L. Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC, provides a summary of the changes to the SOFA assessments and corresponding scoring now that JAMA Network Open recently published the consensus statement Rational and Methodological Approach Underlying the Development of the Sequential Organ Failure Assessment (SOFA)-2 Score. Note : To access this free article, make sure you first register if you do not have a paid subscription.
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.
A study published in JAMA found that people who experience a traumatic spinal cord injury are at a greater risk of developing long-term chronic conditions such as hypertension, stroke, heart disease, diabetes, and other neurological and psychiatric conditions.
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.
Discover how Nancy Blattberg-Smith, MPH, RHIA, CDIP, CCS, and Michelle Knuckles, RHIA, CDIP , have helped build a functional coding, CDI, auditing, and education model that can improve cross-functional resources, communication, and education for developing integrated DRG denial strategies.
Asthma and chronic obstructive pulmonary disease, which encompasses emphysema and bronchitis, are two of the most prevalent and debilitating respiratory conditions. Understanding these diseases and their pathophysiology is crucial for accurate diagnosis, treatment, and coding, particularly when the conditions overlap. Note : To access this free article, make sure you first register if you do not have a paid subscription.
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?
When a woman is pregnant, relational connections between multiple organ systems can affect both mother and fetus and thereby alter, and perhaps complicate, the care they require. In addition, determining whether a condition was pre-existing or due to the pregnancy is important but can be tricky. Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I, provides clarifications for these types of scenarios.
A study published in the Journal of the American College of Cardiology found that people under age 50 who consume cannabis are 6.2 times more likely to experience a heart attack than individuals who do not. It also found that they are 4.3 times more likely to experience an ischemic stroke and 2 times more likely to experience heart failure.
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.
Terry Tropin, MSHAI, RHIA, CCS-P , delves into the 2026 ICD-10-PCS updates that include complicated bypass, restriction, and transfer procedures, which previously could not be specifically coded. Also included are some new devices that require their own code.
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.
Our experts answer questions on new codes introduced to differentiate multiple sclerosis subtypes, the must know concept of Elixhauser comorbidities, and key questions to address prior to coding chest pain.
Coding practices by Medicare Advantage insurers make members seem sicker, which resulted in an extra $33 billion in payments from the federal government in 2021, relative to coding by traditional Medicare providers, according to a study published by the Annals of Internal Medicine .
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.
Cardiomyopathy refers to a group of conditions in which the heart muscle becomes diseased, making it harder for the body to pump blood effectively to the rest of the body . While accurate ICD-10-CM coding of cardiomyopathy requires precise documentation of the cause (if known) and complications, the type will drive the final code choice. Note : To access this free article, make sure you first register if you do not have a paid subscription.
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.
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...
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.
CMS recently released an updated MLN fact sheet reminding providers when a transcatheter tricuspid valve replacement for symptomatic tricuspid regurgitation can be covered under the coverage with evidence development policy. Included are the ICD-10-CM/PCS codes that must be reported for inpatient cases.
Terry Tropin, MSHAI, RHIA, CCS-P, reviews the third quarter publication of Coding Clinic , which added clarifications for complicated coding procedures that may require more than one code when performed together, depending on the objective of each procedure.
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.
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.
There are 116 new ICD-10-CM codes available for chronic non-pressure skin ulcers, added for FY 2026. Nancy Reading, BS, CPC, CPC-P, CPC-I, explores these new codes and how they were added in response to a growing problem identified as xylazine-induced skin ulcers.
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.
Payers are further along in the AI process as they use AI to scrub claims against their policies, which many believe is contributing to the recent uptick in denials. As organizations attempt to catch up with technological advancements and defend themselves against payers’ new tactics, departments such as coding, CDI, and revenue cycle should be prepared for increased AI integration and determine the best ways to utilize the technology.
Beginning October 1, 2025, there will be 116 new ICD-10-CM codes available for chronic non-pressure skin ulcers, added for FY 2026. Nancy Reading, BS, CPC, CPC-P, CPC-I , explores these new codes and how they were added in response to a growing problem identified as xylazine-induced skin ulcers.
A study published by the Journal of the American Heart Association found that ischemic heart disease death rates fell 81% from 1970 to 2022 while deaths from heart attacks decreased 89%. However, deaths from other types of heart disease increased by 81% during the same period.
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.
Terry Tropin, MSHAI, RHIA, CCS-P , delves into the 2026 ICD-10-PCS updates that include complicated bypass, restriction, and transfer procedures, which previously could not be specifically coded. Also included are some new devices that require their own code.
Respiratory failure is a life-threatening condition that occurs when the respiratory system is unable to maintain adequate gas exchange. Accurate coding of this condition ensures that healthcare providers can effectively communicate the severity of the condition, track patient outcomes, and avoid misclassification. Note : To access this free article, make sure you first register if you do not have a paid subscription.
It is not unusual for a professional medical coder to determine the need for multiple ICD-10-PCS procedure codes to tell the whole story about the care a patient has received during a current admission. Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I , shows how to begin by first referring to sequencing guidelines for principal and secondary ICD-10-CM diagnosis codes.
Learn how HIM professionals, including coders, can leverage data related to social determinants of health to improve patient care and secure proper reimbursement.
The Agency for Healthcare Research and Quality has released the 2025 Patient Safety Indicators (PSI) updates and revisions. Review the changes in more detail and discover which outdated indicators have been removed and which indicators have been modified.
While many bone fractures are often treated in emergency rooms or orthopedic clinics, certain fractures—especially severe, complex, or high-risk ones—tend to require inpatient admission. Nancy Reading, BS, CPC, CPC-P, CPC-I , shows how recognizing severity of fractures that may warrant hospitalization helps coders capture the full scope of the patient’s condition.
It is not unusual for a professional medical coder to determine the need for multiple ICD-10-PCS procedure codes to tell the whole story about the care a patient has received during a current admission. Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I , shows how to begin by first referring to sequencing guidelines for principal and secondary ICD-10-CM diagnosis codes.
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?
Cirrhosis of the liver is categorized into distinct types that reflect different patterns of liver injury and disease progression, including hepatic fibrosis and hepatic sclerosis. Proper identification of these forms is critical for clinical accuracy and coding compliance.
With takeaways from three certified medical professionals, HIM professionals can discover how the complexity of care for major depressive disorder impacts decisions around admissions, treatment intensities, resource allocations, and service quality, beginning with outpatient care.
Because anemia is not a definitive diagnosis due to the condition having many possible causes and just as many clinical presentations, Nancy Reading, BS, CPC, CPC-P, CPC-I , visits several of the common etiologies for anemia as well as associated coding concerns.
CMS recently released an updated MLN fact sheet reminding providers when implantable pulmonary artery pressure sensors for heart failure can be covered under the coverage with evidence development policy. Included are the ICD-10-CM/PCS codes that must be reported for inpatient cases.
Q: Are there solutions for having better coding and CDI collaboration? How might this help teams with escalation processes and implementation of AI programs?
As the healthcare landscape evolves with new diseases, technologies, and treatment methodologies, so too must the guidelines that support the ICD-10-CM coding system. Review updates to the ICD-10-CM Official Guidelines for Coding and Reporting for fiscal year 2026 that will become effective October 1. Note : To access this free article, make sure you first register if you do not have a paid subscription.
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.
CMS released the fiscal year 2026 Inpatient Prospective Payment System final rule on July 31, which will provide a 2.6% payment increase for hospitals instead of the original 2.4% considered in the proposed rule. Among other provisions, the rule will continue the mandatory Transforming Episode Accountability Model and modify various quality reporting programs.
Terry Tropin, MSHAI, RHIA, CCS-P , outlines changes to the ICD-10-PCS for fiscal year 2026, which were made primarily in the codes for the cardiovascular system, joints and bones, and nervous system. Some of these changes were in the Medical and Surgical section but others were in the New Technology and Extracorporeal or Systemic Assistance and Performance sections.
Are you passionate about sharing your knowledge and looking to make an impact in medical coding? Are you an experienced coding professional with inpatient, outpatient, pro-fee, specialty, or...
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.
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.
Temperatures in the upper 90s and spikes into the low 100s can bring an increased risk of hospitalization for heat-related illnesses, especially in those areas which do not traditionally experience these outside intensities. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , provides guidance for reporting both diagnosis and procedure codes for sun poisoning and heatstroke admissions.
While many bone fractures are often treated in emergency rooms or orthopedic clinics, certain fractures—especially severe, complex, or high-risk ones—tend to require inpatient admission. Nancy Reading, BS, CPC, CPC-P, CPC-I , shows how recognizing severity of fractures that may warrant hospitalization helps coders capture the full scope of the patient’s condition.
Temperatures in the upper 90s and spikes into the low 100s can bring an increased risk of hospitalization for heat-related illnesses, especially in those areas which do not traditionally experience these outside intensities. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , provides guidance for reporting both diagnosis and procedure codes for sun poisoning and heatstroke admissions.
With the fiscal year (FY) 2026 ICD-10-CM update adding 487 new diagnosis codes, inpatient coders will have the opportunity to report conditions with more specificity in areas such as wound care, ophthalmology, neurology, nephrology, pathology, and chronic disease coding. Note : To access this free article, make sure you first register if you do not have a paid subscription.
A recent Springer Nature study found an increase in Acinetobacter baumannii infections between 2018 and 2021 and carbapenem-resistant A. baumannii (CRAB) infections between 2018 and 2022. The presence of the bacteria was identified in 1% of hospitalized U.S. patients, and over one third of A. baumannii cases were CRAB, designated by the WHO as a critical pathogen in need of new antibiotics.
CMS recently published the fiscal year 2026 ICD-10-PCS code set and official guidelines. Although CMS made no significant changes to the guidelines, the ICD-10-PCS code set includes 156 new codes, 27 deleted codes, and four new tables.
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.
Terry Tropin, MSHAI, RHIA, CCS-P , clarifies the featured terms and interventions of Coding Clinic ’s ICD-10-PCS second quarter update so that coders can comprehend and accurately apply procedure codes in specific scenarios.
Reporting aneurysm repairs can appear almost as complex as the procedure itself. However, Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , shows how taking it one character at a time and using the helpful guidelines and descriptors provided within ICD-10-PCS will allow coders to master this accurately and quickly.
Reporting aneurysm repairs can appear almost as complex as the procedure itself. However, Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , shows how taking it one character at a time and using the helpful guidelines and descriptors provided within ICD-10-PCS will allow coders to master this accurately and quickly.
With its enhanced specificity and comprehensive structure, ICD-11 offers a more detailed and accurate framework for documenting cancer diagnoses. Karla VonEschen, MS, CCDS-O, CPC, CPMA , explores how precise documentation and the coder’s ability to capture all the diagnosis codes to fully describe the condition will be crucial for healthcare organizations.
Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM , walks through the evolution of sepsis definitions that reflect the growing sophistication in our understanding of how the body responds to infection. Understanding the history not only helps contextualize definition variations in provider documentation but also has important implications for coding and reimbursement.
Our experts answer questions on organizing clinical validation queries, the difficulty of diagnosing skin failures, and establishing an organizational definition of sepsis.
While much of the focus on AI implementation in HIM centers around billing and coding for operational efficiency and error reduction, its value extends far beyond those boundaries. Looking ahead, the stakes involve deeper questions about how automation might ultimately influence clinical decision-making.
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.
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.
CMS recently announced plans to enhance its auditing efforts for Medicare Advantage plans by increasing the number of audits it conducts and expanding its team of medical coders.
Accurate coding of hepatitis C scenarios relies heavily on recognizing and interpreting key details within clinical documentation, paying close attention specifically to the type of hepatitis, the acuity of the condition, the current status of the disease, and any associated complications or comorbidities. Note : To access this free article, make sure you first register if you do not have a paid subscription.
With its enhanced specificity and comprehensive structure, ICD-11 offers a more detailed and accurate framework for documenting cancer diagnoses. Karla VonEschen, MS, CCDS-O, CPC, CPMA , explores how precise documentation and the coder’s ability to capture all the diagnosis codes to fully describe the condition will be crucial for healthcare organizations.
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.
The National Institutes of Health recently released a study that found an artificial intelligence screening tool was as effective as healthcare providers in identifying hospitalized adults at risk for opioid use disorder and referring them to inpatient addiction specialists. The tool also has the potential to reduce readmissions.
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.
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.
