With the fiscal year (FY) 2026 ICD-10-CM update adding 487 new diagnosis codes, inpatient coders will have the opportunity to report conditions with more specificity in areas such as wound care, ophthalmology, neurology, nephrology, pathology, and chronic disease coding. Note : To access this free article, make sure you first register if you do not have a paid subscription.
While many bone fractures are often treated in emergency rooms or orthopedic clinics, certain fractures—especially severe, complex, or high-risk ones—tend to require inpatient admission. Nancy Reading, BS, CPC, CPC-P, CPC-I , shows how recognizing severity of fractures that may warrant hospitalization helps coders capture the full scope of the patient’s condition.
A recent Springer Nature study found an increase in Acinetobacter baumannii infections between 2018 and 2021 and carbapenem-resistant A. baumannii (CRAB) infections between 2018 and 2022. The presence of the bacteria was identified in 1% of hospitalized U.S. patients, and over one third of A. baumannii cases were CRAB, designated by the WHO as a critical pathogen in need of new antibiotics.
Temperatures in the upper 90s and spikes into the low 100s can bring an increased risk of hospitalization for heat-related illnesses, especially in those areas which do not traditionally experience these outside intensities. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , provides guidance for reporting both diagnosis and procedure codes for sun poisoning and heatstroke admissions.
CMS recently published the fiscal year 2026 ICD-10-PCS code set and official guidelines. Although CMS made no significant changes to the guidelines, the ICD-10-PCS code set includes 156 new codes, 27 deleted codes, and four new tables.
Reporting aneurysm repairs can appear almost as complex as the procedure itself. However, Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , shows how taking it one character at a time and using the helpful guidelines and descriptors provided within ICD-10-PCS will allow coders to master this accurately and quickly.
Excluding skin cancer, breast cancer and prostate cancer are the most frequently diagnosed cancers among women and men, respectively. While both diseases originate in gender-specific organs and can range from slow-growing to aggressive forms, their clinical presentation and diagnostic complexity differ—differences that are reflected in how they are medically coded. 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 , clarifies the featured terms and interventions of Coding Clinic ’s ICD-10-PCS second quarter update so that coders can comprehend and accurately apply procedure codes in specific scenarios.
Differentiating between acute kidney injury and acute tubular necrosis is particularly critical due to their implications on medical complexity and coding classification, so Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , explores the clinical foundation and diagnostic criteria of AKI and ATN, emphasizing their distinctions and significance for clinical documentation integrity and accurate ICD-10-CM coding.
CMS recently announced plans to enhance its auditing efforts for Medicare Advantage plans by increasing the number of audits it conducts and expanding its team of medical coders.
While much of the focus on AI implementation in HIM centers around billing and coding for operational efficiency and error reduction, its value extends far beyond those boundaries. Looking ahead, the stakes involve deeper questions about how automation might ultimately influence clinical decision-making.
ICD-10-CM codes for Parkinson’s disease differ based on the primary neurologic diagnosis and any complications or comorbidities involved, as PD can manifest in various forms, each with unique characteristics.
Social issues often get left out of the conversation when providers, caregivers, and patients are busy, stressed, and focused on the immediate problem that occasioned a visit or admission; however, Nicole Nodal-Rodriguez, MSN, RN, CCDS , considers how having SDOH carried through the record can have a trickledown effect on treatment plans, identification of health disparities, and community services.
With its enhanced specificity and comprehensive structure, ICD-11 offers a more detailed and accurate framework for documenting cancer diagnoses. Karla VonEschen, MS, CCDS-O, CPC, CPMA , explores how precise documentation and the coder’s ability to capture all the diagnosis codes to fully describe the condition will be crucial for healthcare organizations.
Accurate coding of hepatitis C scenarios relies heavily on recognizing and interpreting key details within clinical documentation, paying close attention specifically to the type of hepatitis, the acuity of the condition, the current status of the disease, and any associated complications or comorbidities. Note : To access this free article, make sure you first register if you do not have a paid subscription.
The National Institutes of Health recently released a study that found an artificial intelligence screening tool was as effective as healthcare providers in identifying hospitalized adults at risk for opioid use disorder and referring them to inpatient addiction specialists. The tool also has the potential to reduce readmissions.
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.
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.
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.
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.
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.
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.
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.
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.
Preventing revenue leakage is one of the core goals of a revenue integrity program, but with numerous sources of potential leaks, meeting this goal is often easier said than done. Michele Bear, DBA, MBA, CHRI, CRCR, CHC, CPC , focuses on key elements of successful revenue integrity programs that can prove to be effective and proactive.
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.
CMS recently proposed hundreds of ICD-10-CM code changes in the 2026 Hospital Inpatient Prospective Payment System proposed rule, including 487 new codes, 38 revised code descriptions, and 28 invalidated codes. The rule also proposes 14 new ICD-10-PCS codes.
Forensic medical coding is a specialized field that combines the precision of medical coding with the complexities of the legal system. Understanding the skills needed and the types of cases in which medical coding is essential becomes crucial to those looking to enter the field. Note : To access this free article, make sure you first register if you do not have a paid subscription.
With 50 new ICD-10-PCS codes implemented on April 1, Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , thoroughly reviews the codes to help inpatient coders accurately apply the updates.
CMS recently issued a bulletin highlighting new Medicare documentation guidelines and providing additional resources for documentation compliance. Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS , outlines the key takeaways from this latest guidance and emphasizes how health information, CDI, and coding teams play a role in compliant documentation.
Review a study based on ICD-10-CM data from the National Vital Statistics System that shows a decline in U.S. drug overdose deaths from 32.6 deaths per 100,000 of the country’s standard population in 2022 to 31.3 deaths per 100,000 in 2023.
Q: A month ago, a patient had undergone an open reduction and internal fixation of a traumatic fracture of the left femur. This afternoon, she was admitted for a severe and deep infection of the left thigh and immediately taken to surgery. An open, wide excisional debridement of the infected skin, subcutaneous tissue, and fascia was carried out, and the internal fixation hardware was removed. Cultures of the fixation pins grew Staphylococcus aureus. Can coders report infections of devices similar to how they would report a wound infection in ICD-10-CM?
The Centers for Medicare & Medicaid Services has pulled information on health-related social needs (HRSN), a subset of broader social determinants of health factors, for state Medicaid and the Children’s Health Insurance Program, potentially making it harder for services that address HRSNs to be covered by these affected programs.
Although typically associated with outpatient services due to their use of HCPCS codes, chargemasters are also crucial in inpatient settings, as they serve as the foundation for billing services rendered during a patient’s hospital stay. Learn how inpatient coders can help maintain the financial health of their organizations through the proper understanding of chargemasters. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Coders play a crucial role in addressing clinical and coding denials, but they are far from alone in this effort. All HIM professionals are working together to create and implement comprehensive strategies that effectively reduce denials, fostering a unified approach to overcoming these challenges.
Review a study based on ICD-10-CM data from the National Vital Statistics System that shows a decline in U.S. maternal mortality rates from 22.3 deaths per 100,000 live births in 2022 to a rate of 18.6 deaths in 2023.
Research of multiple countries on various continents and with varied complexity of healthcare environments reveals significant disparities in health outcomes and access to healthcare, and a staggering percentage of health outcomes are attributed to social determinants of health. Studying these countries shows differences in how socioeconomic issues are captured in documentation and coded using different patient classification systems, guidelines, and regulations.
ICD-10-CM official guidelines once stated that if there is conflicting documentation in the health record, the documentation of the attending physician supersedes that of any other provider. With that rule now gone, Cheryl Ericson, RN, MS, CCDS, CDIP , helps clarify who should be determining diagnoses.
One of the most frequent causes of hospital-acquired AKI is acute tubular necrosis (ATN). Improving documentation and coding practices for ATN involves not only recognizing the condition but also realizing the impact of coding ATN versus AKI, addressing common misconceptions in the HIM field, and fostering collaboration among CDI specialists, coding professionals, and providers. Note : To access this free article, make sure you first register if you do not have a paid subscription.
