Services provided in an inpatient setting are reported using two different coding systems. The facility reports procedures using ICD-10-PCS codes while the individuals providing the care report professional services using CPT codes. Terry Tropin, MSHAI, RHIA, CCS-P, provides a glimpse into how these two coding systems can work together in order to fully report inpatient services.
One of the challenges in coding personality disorders is that the terminology used in clinical documentation may not always match the formal diagnostic title listed in ICD-10-CM. Understanding the clarifying and inclusion terms associated with personality disorder codes helps ensure accurate code assignment, reduces the risk of miscoding similar-sounding disorders, and supports complete and compliant clinical documentation. Note : To access this free article, make sure you first register if you do not have a paid subscription.
CMS recently published the fiscal year 2027 ICD-10-PCS code set and official guidelines. Although CMS made no significant changes to the guidelines, the ICD-10-PCS code set includes 101 new codes, 38 deleted codes, and one new table.
A recent study published in the Journal of the American College of Surgeons suggests that postoperative physical activity levels measured by wearable devices were significantly associated with key surgical outcomes, finding that every 1,000 steps taken per day by patients after surgery is linked to fewer complications, lower readmission rates, and shorter hospital stays.
Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, explores the governmental scrutiny around risk adjustment documentation, coding, reporting, and accuracy following the release of a governmental report and press release.
Human immunodeficiency virus is a chronic viral infection with clinical manifestations that can range from an asymptomatic infection to AIDS, the most advanced stage of the disease. Because HIV-related diagnoses carry unique ICD-10-CM coding guidelines, coders must carefully review the medical record to determine whether the documentation supports assignment of HIV disease, asymptomatic HIV infection, or other HIV status, as well as the presence of any HIV-related illnesses.
Comorbid conditions or complications (CC) and major comorbid conditions or complications (MCC) indicate a higher level of severity of illness, an elevated risk of mortality, and an above average intensity of resource utilization. Given their impact on reimbursement and quality reporting, Nancy Reading, BS, CPC, CPC-P, CPC-I, emphasizes how success in coding CCs and MCCs requires a delicate balance of documentation specificity and clinical clarity in diagnosis assignment.
Our experts answer questions on assigning ICD-10-CM P codes versus Z codes for newborn conditions, using artificial intelligence to improve documentation and coding workflows, and coding postsurgical malabsorption.
Assigning and sequencing diagnosis codes for COPD in the face of an acute exacerbation of COPD, particularly when the patient’s condition progresses to respiratory failure, has posed challenges to coders for quite a while. Nancy Reading, BS, CPC, CPC-P, CPC-I, demonstrates how to nail down the diagnosis codes based on clinical presentations before determining the correct sequencing for principal diagnosis assignment.
Hospitals are seeing an increasing number of clinical validation denials that are frequently linked to documentation that does not fully describe the clinical severity of the patient’s condition, even though the documentation technically meets coding requirements. One helpful way to approach this issue is by recognizing inpatient severity drivers—such as physiological instability, organ dysfunction, and treatment intensity—in order to understand the true severity of illness in hospitalized patients.
Imaging services are used by healthcare professionals to provide a non-invasive way of looking inside the human body. For coders, piecing together ICD-10-PCS codes to report the imaging services involves understanding the unique structure of the Imaging section and applying the correct characters to reflect the procedure performed. Follow Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , as she delves into the section.
According to preliminary data released by the CDC, the number of births in the United States continued its gradual decline in 2025, reflecting long-term demographic trends and shifting reproductive patterns. The general fertility rate also edged downward, marking a continuation of a long-term decline that began in 2007. Other results included in the data relate to teen birth rates, cesarean delivery rates, low-risk cesarean rates, and preterm birth rates.
Q: How is artificial intelligence being used in healthcare today, and what role can AI play in improving documentation and coding workflows while still requiring human oversight?
Diagnosing opportunistic infections can be particularly challenging because the presenting signs and symptoms are nonspecific and may resemble a wide range of other conditions, making it difficult for providers to immediately identify the exact infectious process. Nevertheless, coders should recognize how clear documentation of both the infection and the underlying pathogen is particularly critical for proper code selection as many ICD-10-CM codes are organism-specific and dependent on the anatomical site or body system involved. Note : To access this free article, make sure you first register if you do not have a paid subscription.
In today’s healthcare revenue cycle, collaboration between coding teams and CDI professionals is essential for accuracy, compliance, and financial performance. At the center of this collaboration is the DRG validation auditor—a role that ensures documentation integrity and optimizes reimbursement. Jennifer Hagen, BSN, RN, CCDS, CDIP, CCS, outlines how a small hospital system transformed its CDI auditor-coder partnership into a high-impact prebill review process.
Imaging services are used by healthcare professionals to provide a non-invasive way of looking inside the human body. For coders, piecing together ICD-10-PCS codes to report the imaging services involves understanding the unique structure of the Imaging section and applying the correct characters to reflect the procedure performed. Follow Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , as she delves into the section.
ICD-11 elevates SDOH and other contextual factors into a more standardized, digital-first framework that can support the next generation of equity measurement, population health analytics, and financing models. Learn how ICD-11 SDOH coding is not just a classification change–it is an enabler of strategic goals in population health, financial sustainability, and equitable care delivery.
Hospitals have had a more complex time attempting to retain fair DRG payment by defending both the documented clinical diagnoses established by the treating provider and the corresponding codes in written appeal. Julie Dagen, RHIA, CCDS, CCS, seeks to address some key aspects of compliant hospital navigation through the rough waters of DRG denials.
Compared to recent past years, CMS proposed fewer ICD-10-CM code changes in the 2027 Hospital Inpatient Prospective Payment System proposed rule, including 184 new codes, 4 revised code descriptions, and 30 invalidated codes.
From a coding perspective, accurate reporting of artificial openings is essential because it communicates critical information about a patient’s anatomy, clinical status, and the level of care required. Coders must distinguish between a stable, well-functioning artificial opening (status), active management or attention to the opening, and true complications, as each circumstance is classified differently within ICD-10-CM. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Q: How do coders determine whether to assign an ICD-10-CM P code (for maternal conditions affecting the newborn) or a Z code (for factors influencing health status) for a newborn?
Six healthcare information management professionals review an initiative at their organization that has provided a structured and sustainable approach to improving the documentation of encephalopathy and offers a replicable framework for addressing documentation challenges of other clinical conditions that are often characterized by diagnostic ambiguity. Such efforts can help ensure appropriate representations of patient acuity, accurate coding practices, sufficient risk-adjustment modeling, and decreased retrospective query burden.
Accurate procedure code assignment requires coders to have a good understanding of coding guidelines, anatomy, physiology, and medical terminology, as well as the ability to decipher the operative report. Assigning ICD-10-PCS codes for pacemaker insertions requires all these skills and more in some cases. Teresa Seville, RHIT, CCS , justifies how understanding the types of pacemakers and where they are inserted is paramount for correct coding.
Our experts answer questions on sequencing ICD-10-CM codes for unintentional poisoning with manifestations and for cases of postprocedural sepsis, as well as ensuring post-discharge query compliance.
For the 10 years we have been working with the ICD-10-PCS code set, these codes, used to report procedures provided to an inpatient, have required seven characters. Each character reports a very specific element of the service provided. Here, Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, is going to focus on character 6 for Device.
Coding for alcohol- and drug-related disorders requires careful attention to both clinical terminology and the structure of the ICD-10-CM classification system. These conditions fall under the broader category of mental and behavioral disorders due to psychoactive substance use, primarily coded within the F10-F19 range. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Accurate procedure code assignment requires coders to have a good understanding of coding guidelines, anatomy, physiology, and medical terminology, as well as the ability to decipher the operative report. Assigning ICD-10-PCS codes for pacemaker insertions requires all these skills and more in some cases. Teresa Seville, RHIT, CCS , justifies how understanding the types of pacemakers and where they are inserted is paramount for correct coding.
Assigning and sequencing diagnosis codes for COPD in the face of an acute exacerbation of COPD, particularly when the patient’s condition progresses to respiratory failure, has posed challenges to coders for quite a while. Nancy Reading, BS, CPC, CPC-P, CPC-I, demonstrates how to nail down the diagnosis codes based on clinical presentations before determining the correct sequencing for principal diagnosis assignment.
CMS released the fiscal year 2027 Inpatient Prospective Payment System proposed rule on April 14, which proposes a 2.4% payment increase for hospitals that are meaningful users of electronic health records and submit quality measure data. A key addition to the proposed rule is a nationwide expansion of the Comprehensive Care for Joint Replacement model.
Q: A patient with dementia has not taken prescribed Lasix for one week due to forgetting and presents with worsening acute heart failure. What is going to be sequenced first: the underdose or the acute heart failure?
Accurate reporting of left-sided heart failure types relies on specific ICD-10-CM codes that align with the documented ejection fraction category, although ICD-10-CM also provides specific codes for other clinically important forms of heart failure, with and without other chronic conditions, that reflect distinct pathophysiologic mechanisms and coding considerations. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Given the rising relevance of encephalopathy, getting a refresher on what the condition is and why it’s relevant to coding and CDI can benefit all professionals no matter their experience level. And because the clinical validation of encephalopathy is not contingent on a lab finding, but a long chain of events that require each link to be well established, organizations are still finding new ways to leverage innovative tactics in order to document it accurately.
At the recent public ICD-10 Coordination and Maintenance Committee Meeting, the Centers for Disease Control and Prevention National Center for Health Statistics discussed 31 proposals involving procedure code topics. Review the updates for two proposals unrelated to the X tables for New Technology that are being considered for implementation on April 1, 2027.
For the 10 years we have been working with the ICD-10-PCS code set, these codes, used to report procedures provided to an inpatient, have required seven characters. Each character reports a very specific element of the service provided. Here, Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, is going to focus on character 6 for Device.
Neonatal intensive care units provide care and additional medical attention for neonates who might be born prematurely, with low birthweight, with a medical complication, or with a congenital anomaly. Follow Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, as she delves into common services performed in these units and how they are reported with ICD-10-PCS codes.
Our experts answer questions on ICD-10-CM coding for adverse effects of medications, ICD-10-PCS coding for stroke intervention procedures, and coding lactic acidosis and sepsis together.
In an effort to streamline the query process and ensure each missive adheres to stringent compliance standards, many programs now rely on templates that coding and CDI professionals can customize for the specific query opportunity at hand. To explore this topic further, ACDIS asked members of the 2025/2026 CDI Leadership Council to share their thoughts on query templates.
ICD-10-PCS coding for procedures performed within the cranial cavity is complicated. Terry Tropin, MSHAI, RHIA, CCS-P, describes the different body part values used for the brain and cranial cavity, root operations used, and coding for some common procedures.
A report published by the American Cancer Society found that colorectal cancer rates among adults younger than 65 continue to increase while rates for older adults continue to decline. The study found that the increase is being driven by a higher prevalence of rectal cancer, which now makes up 32% of all colorectal cancer diagnoses, up from 27% in the mid-2000s.
Q: How are stroke intervention procedures like angioplasty, transfemoral carotid artery stenting, and transcarotid arterial catheterization coded using ICD-10-PCS, and how does ICD-10-PCS handle the coding of new technology devices?
At the recent public ICD-10 Coordination and Maintenance Committee Meeting, the Centers for Disease Control and Prevention National Center for Health Statistics discussed a draft proposal involving an expansion of sepsis diagnosis coding. Review the updates being considered for implementation on April 1, 2027. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Porcelain aorta is a disease that is caused by severe and widespread hardening of the walls of the ascending aorta that reaches to the aortic arch and descending aorta. Although there are several methods used to diagnose porcelain aorta, Brandi Hutcheson, RN, MSN, CCM, CCDS, CCA, says there is not a clear consensus on how it should be diagnosed.
ICD-10-PCS coding for procedures performed within the cranial cavity is complicated. Terry Tropin, MSHAI, RHIA, CCS-P, describes the different body part values used for the brain and cranial cavity, root operations used, and coding for some common procedures.
According to data from the Centers for Disease Control and Prevention, the U.S. recorded 649 maternal deaths in 2024. While the total number of deaths declined slightly from 669 deaths in 2023, the overall maternal mortality rate showed no statistically significant improvement, highlighting ongoing challenges in maternal health outcomes.
Q: What steps should medical coders take to correctly code adverse drug effects in ICD-10-CM, and when should a provider query be submitted if documentation is unclear or unspecific?
In December 2023, the Office of the Inspector General published a toolkit for Medicare Advantage organizations who submit high-risk diagnoses, and it announced in January 2026 that an audit will be conducted on high-risk codes that the organizations submitted for 2024. Nancy Reading, BS, CPC, CPC-P, CPC-I, reviews the high-risk codes and emphasizes what to look for in the documentation to support coding practices.
From an inpatient coding perspective, vascular dementia may be documented for hospitalized patients because it coexists with other acute or chronic medical conditions. Accurate coding of the condition and its associated risk factors and complications will ensure the patient’s overall severity of illness and complexity of care are fully captured. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Recovery auditors and payers have demonstrated an eagerness to exploit what providers routinely state in the medical record to facilitate additional DRG validation and medical necessity denials. Therefore, knowing what should not be said in a medical record is worth reviewing. To illustrate, Trey La Charité, MD, FACP, SFHM, CCS, CCDS, lists 10 things providers should never be documenting in the medical record.
