Our experts answer questions about coding for controlled puerperium diabetes and endoscopic procedures as well as provide suggestions for referring to prior encounter information in queries.
Shelley C. Safian, PhD, MAOM/HSM/HI, RHIA , explains ways administration can establish an organizational culture of legal and ethical responsibilities to maintain compliance and honor patients and staff.
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.
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.
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?
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.
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.
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?
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.
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.
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.
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.
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.
Q: A 64-year-old female patient who has a bilateral lung transplant presents with COVID-19 (reason for admission) with acute respiratory failure. She also has immunosuppression from drugs. How would this scenario be reported in ICD-10-CM?
Nancy Reading, RN, CPC, CPC-P, reviews the Phoenix Sepsis Score, a new set of clinical parameters to define and diagnose pediatric sepsis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The success of coding and CDI departments depends on collaboration with multiple entities. Laurie L. Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , illuminates how to promote healthy partnership.
Shelley C. Safian, PhD, MAOM/HSM/HI, RHIA , explains ways administration can establish an organizational culture of legal and ethical responsibilities to maintain compliance and honor patients and staff.
CMS recently published the fiscal year 2025 ICD-10-PCS code set and guidelines. Although CMS made no changes to the guidelines, the update includes 371 new codes, 61 deleted codes, and three new tables.
JoAnn Baker, CCS, CPC, COC , defines sepsis and septic shock, and delves into the emerging initiative to integrate AI into the diagnosis and treatment process.
Verbal conversations with providers regarding reportable conditions and procedures are considered verbal queries. Refresh how they should be memorialized within the record to maintain compliance. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: A 64-year-old female inpatient has hepatocellular cancer with an orthotropic liver transplant with bile duct obstruction and is immunosuppressed due to drugs. Which ICD-10-CM codes would be reported?
Kathy Dorich, MSN, RN, CCDS, CPHQ , explains two types of DRG reconciliation processes that she has implemented to alleviate conflict between coding and CDI departments.
A study published in the Journal of the American Medical Association found that four popular pretest risk assessment models for evaluating risk of hospital-acquired venous thromboembolism in inpatients did “not perform particularly well.”
JoAnn Baker, CCS, CPC, COC , defines sepsis and septic shock, and delves into the emerging initiative to integrate AI into the diagnosis and treatment process.
Our experts answer questions about querying a metabolic encephalopathy diagnosis and documenting the start of mechanical ventilation if a patient is intubated in another ED.
Managing chronic conditions requires involvement from many parties, making documentation challenging. Assess how to improve documentation and reimbursement for chronic conditions with tips provided by Arta Kelmendi-Doko, MD, PhD . Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: A patient has acute renal failure due to dehydration, a history of Type 1 diabetes mellitus causing end-stage renal disease, a kidney transplant two years ago, and chronic kidney disease stage 3a, immunosuppressed by their drugs. How would this be reported in ICD-10-CM?
Brandi Hutcheson, RN, MSN, CCM, CCDS, CCA , examines the coding and clinical literature on malnutrition and obesity to see how coders can reconcile these seemingly disparate diagnoses.
A Journal of the American Medical Association study found that ICD-10-CM influenza codes accurately represented cases of positive diagnoses in pediatric patients, but their sensitivity was modest.
Q: A 64-year-old female bilateral lung transplant recipient presents with aspiration pneumonia, hypoxia, and has immunosuppression from the drugs. How would this scenario be reported in ICD-10-CM?
Pressure injuries, which can lead to a patient safety indicator (PSI), require clear documentation and coordination among coding, CDI, and clinical departments. Katherine Siemens, RN, BSN, CMSRN, CCDS , evaluates how poor coordination could result in a PSI being incorrectly reported.
Despite the expansion of codes that came with the transition from ICD-9 to ICD-10-CM, the majority of codes for inflammatory arthritis were not frequently used in 2015 through 2021, researchers found.
Merle Zuel, RN, CCDS , explains how healthcare leaders can improve in their roles by understanding all coding and clinical data available and knowing how to analyze it.
Sarah McDonald, CPC , reviews ICD-10-CM and ICD-10-PCS coding guidelines for the U.S.’ most common orthopedic surgeries: hip and knee replacements. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Pressure injuries, which can lead to a patient safety indicator (PSI), require clear documentation and coordination among coding, CDI, and clinical departments. Katherine Siemens, RN, BSN, CMSRN, CCDS , evaluates how poor coordination could result in a PSI being incorrectly reported.
This article reviews malware basics and covers tips that healthcare employees can implement to avoid cyberattacks that could put protected health information (PHI) at risk.
by Jess Fluegel It is a truth universally acknowledged that a CDI department, in possession of a part-time physician advisor who is already stretched too thin, may be in want of provider engagement...
Q: How would the scenario of a previous kidney transplant patient presented with sepsis due to acute pyelonephritis (E. coli), CKD, and immunosuppression be reported in ICD-10-CM?
CMS’ fiscal year 2025 IPPS proposed rule and fact sheet, published April 10, includes proposals for a 2.6% payment increase, a new bundled payment program, code updates, and other policy changes.
This article reviews malware basics and covers tips that healthcare employees can implement to avoid cyberattacks that could put protected health information (PHI) at risk.
Sarah McDonald, CPC , examines the ICD-10-CM/PCS coding conventions for symptoms, stages, and treatment of gastroesophageal reflux disease—a commonly diagnosed digestive disorder in the U.S. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Educating clinical staff on proper documentation of mechanical ventilation can avoid compliance issues and support accurate reimbursement. This article clarifies the complications of reporting mechanical ventilation in ICD-10-PCS.
Sarah McDonald, CPC , explains the spinal fusion process and overviews the process of constructing ICD-10-PCS procedure codes character by character. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Kate Siemens, RN, BSN, CMSRN, CCDS , offers tips on how coders and CDI can assess patient safety indicators to improve reporting accuracy and increase quality of care.
The pediatric population is smaller and involves different clinical and nuances, but this often-underdeveloped area of coding can be a source of missed revenue if left uninvestigated.
Q: Aside from Coding Clinic , Third Quarter 2005, pp. 19–20, is there any more up-to-date advice on reporting ICD-10-CM diagnoses from physician orders?
The Journal of the American Medical Association (JAMA) published a study that found that high-flow nasal cannula protocols were associated with a 6.1% reduction in ICU admissions among children.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS, analyzes the challenges that both inpatient and outpatient CDI specialists encounter and offers advice to lessen provider opposition to participating in outpatient CDI.
Many CDI professionals are familiar with the saying that, since CDI is “already in the chart,” they can easily pick up a new review lens. The reality, however, is that each new responsibility can put a damper on staff bandwidth and productivity.
Educating clinical staff on proper documentation of mechanical ventilation can avoid compliance issues and support accurate reimbursement. This article clarifies the complications of reporting mechanical ventilation in ICD-10-PCS.
Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , summarizes guidance from the 2024 first quarterly release of Coding Clinic , including reporting for postoperative complications, non-traumatic kidney injuries, and vertebral artery dissection.
Sarah McDonald, CPC , analyzes the process of reporting traumatic brain and spinal cord injuries ICD-10-CM, notably the cause of injury, reason for the encounter, and aftereffects. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
This article explains the quality metrics of hospital-acquired infections and accidental punctures and lacerations, and details how collaborative efforts can reduce these risks.
Terry Tropin, MSHAI, RHIA, CCS-P , continues her exploration of ICD-10-PCS April updates with added options for intracranial brachytherapy, electroporation, sinus dilation, pedicled omentoplasty, and more. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Shannon Oitker, MSN, RN , reviews the nine MS-DRGs for ventilator use, explains how DRGs are designed, and assesses whether hospitals are receiving adequate reimbursement for ventilation services.
Susan G. Michael, MSN, RN, CPHQ, CCDS , examines social determinants of health through a historical perspective and explains how they evolved into the codes that coders and researchers use today.
CMS will be holding its next ICD-10 Coordination and Maintenance Committee meeting March 19-20. The committee will deliberate applications for new ICD-10-PCS and ICD-10-CM code assignments. If approved, the codes will become effective October 1, 2024.
This article explains the quality metrics of hospital-acquired infections and accidental punctures and lacerations, and details how collaborative efforts can reduce these risks.
Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , summarizes guidance from the 2024 first quarterly release of Coding Clinic , including reporting for postoperative complications, non-traumatic kidney injuries, and vertebral artery dissection.
Shannon Oitker, MSN, RN , reviews the nine MS-DRGs for ventilator use, explains how DRGs are designed, and assesses whether hospitals are receiving adequate reimbursement for ventilation services.
Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, and Karla VonEschen, MS, CPC, CPMA, CCDS-O, look back at the progression of diagnosis and mortality coding before looking ahead to ICD-11 and how coding departments can prepare for it.
Although every professional may be different, there are a few tricks of the trade to building the right garden and letting your CDI department show off some of that natural talent.
TaraJo Vaught, MSN, RN, CCDS , shines a light on the crucial roles played by coding and CDI specialists, compares their respective realms, and offers insights for transitioning between them.
A recent study has suggested that COVID-19 patients who have a history of inflammatory bowel disease (IBD) are at an increased risk of sepsis, shock, and acute kidney injury.
Terry Tropin, MSHAI, RHIA, CCS-P , explores the 2024 ICD-10-PCS updates that will become effective April 1. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, and Karla VonEschen, MS, CPC, CPMA, CCDS-O, take a look back at the progression of diagnosis and mortality coding before looking ahead to ICD-11 and how coding departments can prepare for it.
Heart failure affects more than 6 million adults in the U.S. and costs the nation more than $30 billion. Review ICD-10-CM guidance and documentation details required for accurately reporting the condition. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Artificial intelligence (AI) has burst on the scene with numerous clinical and coding applications for providers. This article looks at how the technology can be used and where human oversight is still required.
Amanda Vincent, MBA, CCS, CPC, CCDS, CRC , analyzes various types of postprocedural complications, such as respiratory failure, infection, ileus, shock, and offers direction on how to report them.
Penny Jefferson, MSN, RN, CCDS, CCDS-O, CCS, CDIP, CRC, CHDA, CRCR, CPHQ , explains how professional development in CDI is a journey, demanding integration of specific knowledge, continuous learning, and adaptability.
Nancy Reading, RN, CPC, CPC-P, examines the complex relationships between ketoacidosis, hyperglycemia, and hyponatremia, and gives advice on reporting these diabetic complications in ICD-10-CM. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: A patient who presents with complaints of progressive neck and bilateral arm symptoms is diagnosed with cervical spondylosis—worse at joints C5-C6 and C6-C7. Which ICD-10-CM codes would be reported?
The CDC posted its updated 2024 ICD-10-CM guidelines in January that include a sequencing update for sepsis due to postprocedural infection. The guidelines will take effect April 1.
Amanda Vincent, MBA, CCS, CPC, CCDS, CRC , analyzes various types of postprocedural complications, such as respiratory failure, infection, ileus, shock, and offers direction on how to report them.
While certifications specific to CDI are by no means a requirement to get into the CDI field, they have grown to become a rite of passage for many CDI professionals.
TaraJo Vaught, MSN, RN, CCDS , shines a light on the crucial roles played by coding and CDI specialists, compares their respective realms, and offers insights for transitioning between them.
Diane Pittman, CPC, CPMA, CRC, CCD-O, and April Russell, MBA, CPC, CPC-P, COC, CRC, CCDS-O, explain how reporting ICD-10-CM social determinants of health, their context, and coder feedback can influence natural language understanding.
Nancy Reading, RN, CPC, CPC-P , explains how employing clinical and coding criteria for assigning or auditing ICD-10-CM codes for malnutrition can have a significant impact on reimbursement. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
April Russell, MBA, CPC, CPC-P, COC, CRC, CCDS-O , and Will Morriss, CCS, CCDS-O , describe how artificial intelligence (AI) has impacted providers, coders, and the healthcare industry.
The AHA responded with potential provider concerns to the government’s recent request for information (RFI) as it prepares for the potential transition from ICD-10 to ICD-11 for morbidity coding.
Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CCS , defines the Diagnosis, Etiology, Evidence, Plan (DEEP) methodology to identify and instill good habits for provider documentation.
2024 ICD-10-CM code changes pertaining to acute appendicitis and small intestinal bacterial overgrowth give coders the opportunity to report these conditions with greater accuracy and specificity. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Amanda Vincent, MBA, CCS, CPC, CCDS, CRC , explains the differing definitions of “complication” for providers vs. coders, reviews types of complications, and codes an intraoperative laceration case study.
Marlene Goodwin-Esola, MSN, RN-BC , recounts her personal journey with heart disease, undergoing cardiac catheterization, and offers her viewpoint on being on the other side of a coding chart.
Professional development in CDI is a multifaceted and continuous journey, demanding integration of specific knowledge, continuous learning, and adaptability.
