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.
Review a study based on ICD-10-CM data from the National Vital Statistics System that shows life expectancy for the United States population increased to 78.4 years in 2023 while the mortality rate decreased by 6.0% to 750.5 deaths per 100,000 of the standard population in 2023. Also determined were leading causes of death.
The ICD-10-CM classifies deep vein thrombosis with a high degree of specificity based on severity, affected extremity, vein location, and laterality, but without detailed clinical documentation or consistent terminology use, coders may need to query providers often for clarification in order to assign the right code.
Jenny Esper, RHIA, CDIP, CCS, CCDS , and Lizabeth Volansky, BSN, RN, CCDS, RHIA, CDIP, CCS , explore the topic of including references or links to definitions within query notes and how such a practice can enhance documentation and coding.
On April 11, CMS released the fiscal year 2026 Inpatient Prospective Payment System proposed rule, which proposes a 2.4% payment increase for hospitals and several adjustments to quality reporting programs, including the Hospital Inpatient Quality Reporting Program.
With hundreds of ICD-10-CM codes available for the various forms and manifestations of osteoarthritis and rheumatoid arthritis, coding these conditions to their highest specificity can be surprisingly complex. Without a thorough understanding of their distinctions, and without clear documentation from providers, navigating this coding landscape can feel overwhelming. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Revenue integrity professionals have found that working with multiple departments is helpful in addressing denials. Discover how coders—alongside denial, clinical, and CDI professionals—can play a key role in this increased collaboration to manage and prevent denials.
Coding for joint replacement procedures requires extra attention to detail, particularly for device and qualifier characters and most importantly for partial replacements. Terry Tropin, MSHAI, RHIA, CCS-P , shows how these characters are very specific but give a clear picture of the procedure that was performed for a specific patient.
AI is increasingly being integrated into the CDI industry and as these tools evolve, their capabilities will naturally extend into adjacent fields like medical coding. Although AI may not be an entirely welcome change, Sarah Matacale, BSN, RN, CCS, CCDS , highlights practical ways CDI professionals and even coders can adapt to and benefit from these new tools.
Our experts answer questions on NICU coding, ICD-10-CM coding for kidney transplants with kidney failure or other complications, and the acceptance of systemwide clinical definitions on queries.
Anemia is a complex condition to manage clinically and document accurately, yet proper diagnosis, documentation, and coding are critical for ensuring appropriate patient care and reimbursement. Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , explores the clinical aspects of anemia, including its definitions, types, causes, and management, while addressing the challenges in clinical documentation and coding.
Coding for joint replacement procedures requires extra attention to detail, particularly for device and qualifier characters and most importantly for partial replacements. Terry Tropin, MSHAI, RHIA, CCS-P , shows how these characters are very specific but give a clear picture of the procedure that was performed for a specific patient.
Misidentifying seizures and convulsions can easily lead to incorrect code assignment as each seizure subtype carries its own specific ICD-10-CM codes. Coding these conditions can be simplified, however, when coders have a strong grasp of the clinical and coding classifications for seizures. Note : To access this free article, make sure you first register if you do not have a paid subscription.
The first quarter publication of Coding Clinic added clarifications for some of the new codes from fiscal year 2025 and a question-and-answer section that discussed complicated coding issues. Terry Tropin, MSHAI, RHIA, CCS-P , reviews the advice and guidelines for ICD-10-PCS codes.
