The redesign of ICD-11 allows for continuous updates, interoperative compatibility with other electronic systems, improved coordination with related terminologies, and a reduced need for post-production clinical modifications. With these changes in mind, Nancy Reading, BS, CPC, CPC-P, CPC-I, explores how this new framework supports significant enhancements to the classification of diagnoses that is built around stem and extension codes and its ability to cluster post-coordinated codes to describe a single condition.
Drug overdose deaths in the United States declined for the third consecutive year in 2025, according to preliminary data released by the Centers for Disease Control and Prevention. The decline marks the longest sustained reduction in overdose deaths in decades and brings the national total back to roughly the level seen in 2019, before the COVID-19 pandemic.
Accurate coding for liver failure requires much more than selecting the correct ICD-10-CM code—it demands an understanding of liver function, disease progression, clinical indicators, and documentation nuances. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Q: When reviewing neurologic cases, what documentation clues, imaging findings, and treatments should coders and CDI specialists look for to identify potential cerebral edema or brain compression diagnoses?
Beyond capturing primary and secondary diagnoses, what goes into a record can hugely impact how a patient is cared for both now and in the future, as well as the trajectory of a community’s health at large. See why it’s essential to go beyond surface-level knowledge and gain a true understanding of how and why SDOH data is important to track, especially for pediatric patients.
The Substance Abuse and Mental Health Services Administration reports about 28.2 million Americans are struggling with drug use disorder, both illicit drugs as well as misuse of prescription medications. The good news is that, with effective treatment, patients can recover and overcome their need or desire for the offending substance. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, illustrates how to capture the diagnosis of such cases first and then put together the treatment codes.
A newly released Office of Inspector General report concluded that unclear Medicare requirements continue to drive inconsistent interpretations of inpatient rehabilitation facility documentation, coverage, billing, and coding rules, contributing to significant payment errors and compliance challenges.
Respiratory syncytial virus and COVID-19 are both types of respiratory viruses, and the symptoms can be very similar and overlap each other. Shontia Leon-Guerrero, CPC, CEDC, CEMC, CPC-I Educator, reviews the signs and symptoms of both conditions in infants and children as well as what coders need to know such as diagnosis codes, procedure codes for vaccine administration, and documentation expectations.
This article examines two examples—bone marrow transplantation and lung transplantation—to illustrate the similarities and differences in coding transplant encounters. These examples demonstrate how transplant coding is largely driven by transplant status, the reason for the encounter, and the presence or absence of transplant-related complications, while highlighting the unique coding considerations associated with specific transplant types. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Coding professionals are fluent in classification systems such as ICD-10-CM/PCS and CPT, which translate documentation into standardized labels and codes for billing, reporting, and quality programs. Laboratory results, however, travel far beyond the claim. Pamela Banning, MLS (ASCP), PMP (PMI), delves into LOINC and SNOMED CT, two international coding systems applied within laboratory information systems to make lab results computable and consistent across computer systems.
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.
Q: When abnormal renal function is documented without a clear diagnosis, what clinical indicators should coders review to determine whether a provider query is warranted?
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.
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.
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.
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.
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.
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?
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.
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.
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.
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.
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.
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.
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.
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?
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?
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.
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.
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.
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.
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?
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.
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.
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.
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.
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?
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.
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.
