Q: A female patient previously had an inpatient stay due to severe enteritis secondary to the use of Keytruda for colon cancer that she was diagnosed with six months earlier. While she has had positive results to the medication, she presented to the ER last week due to severe abdominal bloating and cramping with diarrhea and stools with large amounts of mucous. She was dehydrated and hypokalemic upon inpatient admission and has a history of depression. Her discharge note indicates that her potassium levels and dehydration are normalized. How would this encounter be reported in ICD-10-CM?
Genetic medicine is an emerging specialty coders will be faced with, and a basic foundation of the science and consequences of genetic anomalies will be helpful going forward. Realizing coders are not expected to be clinical, Nancy Reading, RN, BS, CPC, CPC-P, CPC-I , shows how it will still be useful to know the basics.
Following questions from Congress on what steps the government should take to eliminate remaining barriers in accessing addiction treatment, the American Hospital Association noted two out of eight policy and regulatory barriers that currently impact inpatient facilities. Learn what the consequences could be if these barriers were addressed.
Because multiple organ disfunction syndrome does not have a specific ICD-10-CM code, coders face the challenge of capturing the full complexity of the condition. Nevertheless, understanding the various organ systems involved and recognizing the specific dysfunctions can help coders accurately report the condition. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Health information management occupies a pinnacle position in the revenue cycle, and although the span of coding’s influence throughout a healthcare organization is very broad, its effects can also be found in numerous revenue cycle spokes, including preregistration and scheduling, coverage approvals, and case management. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Because substance use, abuse, and dependence are critical areas within healthcare that impact CDI and coding, Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , provides readers with an in-depth analysis of these conditions and emphasizes their clinical, diagnostic, and coding implications.
In a recent release published by the WHO and CDC, new estimates revealed cases of measles are surging worldwide due to inadequate immunization coverage. Coders should explore the implications of this outbreak, as they play a critical role in supporting healthcare systems manage vaccination efforts and protect public health.
Marc Hartstein, MA , brings together all the major highlights of Medicare’s newest Inpatient Prospective Payment System, allowing coders to stay informed about key updates and navigate the changes throughout the year.
Q: A frail 74-year-old female presents with severe shortness of breath and hypoxia. She has a known history of smoking two or more packs per day for the past 40-50 years and has a complex history of chronic obstructive emphysema, centrilobular emphysema, bronchiectasis, and pulmonary hypertension. Her current hospitalization is due to MRSA pneumonia with planned discharge to home health for continued care. How would this diagnostic note be reported in ICD-10-CM?
Coding certification can offer valuable benefits across various medical roles, improving accuracy and communication in clinical settings. Hassan Rao, MD, CPC, CCS , explores how coding knowledge can specifically enhance the effectiveness of CDI physician advisors in optimizing documentation and compliance.
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.
Genetic medicine is an emerging specialty coders will be faced with, and a basic foundation of the science and consequences of genetic anomalies will be helpful going forward. Realizing coders are not expected to be clinical, Nancy Reading, RN, BS, CPC, CPC-P, CPC-I , shows how it will still be useful to know the basics.
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.
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!
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.
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?
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.
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.
