The terms “admission” and “observation” are often confused. Dawn Valdez, RN, LNC, CCDS, CDIP, distinguishes between these terms and evaluates ICD-10-CM coding for patients who begin in observation and are later admitted to the hospital for more intensive care.
Coding and billing professionals must ensure that medical record information is accurate, up to date, and compliant. In this article, Holly Cassano, CPC, CRC , defines late entries, corrections, and addendums, and explains the proper methods used to alter health records while maintaining Medicare compliance.
Kathy Shumpert, MSN, RN, CCDS, writes about the evolution of the denials and appeals process at her facility and discusses tactics to improve communications and efficiency.
Coding for newborn services can be complicated due to detailed examinations and therapeutic treatments performed after delivery. Sarah Nehring, RHIA, CCS, CCDS , breaks down ICD-10-CM coding for newborn encounters and reviews new codes for newborn apnea that took effect October 1.
Pregnancy causes changes to the immune system that increase the risk of infection and sepsis during pregnancy, labor, and the puerperium. Sarah Nehring, BS, RHIT, CCS, CCDS , analyzes ICD-10-CM documentation and coding for sepsis after childbirth.
Social determinants of health ICD-10-CM codes have become more of a hot topic in the CDI world over the past few years. Review guidance for reporting personal circumstances such as income, wealth, and education that impact health and wellbeing.
A recent medical record review published in the Journal of the American Medical Association Network Open found that between October 1, 2021, and January 31, 2022, providers used ICD-10-CM code U09.9 (post-COVID-19 condition, unspecified) to identify a multitude of post-acute conditions brought on by COVID-19.
Stroke, or cerebrovascular accident (CVA), is the fifth leading cause of death in the U.S. and the second leading cause of death worldwide, according to the Centers for Disease Control and Prevention. Unpack clinical documentation and ICD-10-CM coding for various types of CVA. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Coders must be familiar with ICD-10-CM reporting guidelines for common neurological conditions. This article unpacks recent updates to the nervous system chapter of ICD-10-CM including 14 new codes for autonomic conditions and fatigue syndromes. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Respiratory failure occurs when the body is unable to provide oxygen to or remove carbon dioxide from the body. Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , breaks down documentation and ICD-10-CM coding for acute and chronic respiratory failure.
A recent review of inpatient medical records published in the Journal of the American Medical Association Network Open from 463 hospitals found significant increases in pregnancy-related complications and maternal death during the COVID-19 pandemic.
A properly calibrated audit tool is key to uncovering educational opportunities for coding and CDI professionals. Dawn Valdez, RN, LNC, CDIP, CCDS, outlines questions for determining an audit focus and for querying providers when documentation is insufficient to support medical necessity.
Pregnancy causes changes to the immune system that increase the risk of infection and sepsis during pregnancy, labor, and the puerperium. Sarah Nehring, BS, RHIT, CCS, CCDS , analyzes ICD-10-CM documentation and coding for sepsis after childbirth.
Coders must be familiar with ICD-10-CM reporting guidelines for common neurological conditions. This article unpacks recent updates to the nervous system chapter of ICD-10-CM including 14 new codes for autonomic conditions and fatigue syndromes.
The 2023 ICD-10-PCS code update includes 331 new codes and 64 code deletions that take effect this week. This article takes a close look at new ICD-10-PCS codes and guidelines for amputations, laser ablation, and aortic valve replacements. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Audits are crucial to helping CDI and coding teams stay up to date with the fast pace of medicine and continual changes to coding guidelines. Dawn Valdez, RN, LNC, CDIP, CCDS , writes about best practices for auditing and application of audit findings .
