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.
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.
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.
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.
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?
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.
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.
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.
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.
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.
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...
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.
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.
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.
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.
