Our experts answer questions about independent historians, the number and complexity of problems addressed at an encounter, and counting discussion of management.
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.
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.
Using her own CDI team as a case study, Yohan O. Paredes, MD, CCDS , shows how the implementation of structured CDI initiatives in pediatric and OB/GYN settings can optimize coding accuracy, regulatory compliance, and financial performance.
Make sure your providers are showing the mental work that goes into evaluating the risk associated with a medication before you count it toward the risk element of an E/M visit that is coded based on medical decision-making.
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.
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.
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.
To make sure your ICD-10-CM codes are correct and complete, you may need to use an X as a placeholder to expand the code to the proper length. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The proposed 2026 Medicare physician fee schedule, released July 14, boosts the Part B conversion factor for calendar year 2026, adds billing opportunities for behavioral health services, previews new codes, and updates the agency’s quality reporting programs.
Q: What if a provider sends a summary of their visit with a patient to the patient’s primary care provider. Is this considered a “discussion” of patient management?
Physical, occupational, and speech therapy are the most common types that people think of when therapy is recommended. However, there is a new type gaining momentum: pelvic floor therapy.
The calendar year 2026 OPPS and ambulatory surgical center (ASC) proposed rule, released on July 15, details payment updates, services covered, outpatient service volume, and quality reporting, among other proposals.
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.
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.
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.
The second quarter edition of Coding Clinic included questions and answers for coding very specific situations not easily found using the Alphabetic Index. Review some of the noteworthy scenarios.
Medicare considers the shoulder to be “a single anatomic structure,” according to the National Correct Coding Initiative policy manual. In this article, find out what that means from a coding standpoint. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Practices turned to two of the X-series modifiers in place of modifier -59 (Distinct procedural service) more than 7 million times in 2023 and saw mixed results with denial rates on the top-billed codes.
CMS recently released the fiscal year (FY) 2026 ICD-10-CM update, which includes 487 new diagnosis codes effective October 1, 2025. The new codes cover a range of diagnoses, so be sure to review the code update files.
Q: What’s the difference between CPT code 90791 (Psychiatric diagnostic evaluation) and 90792 (Psychiatric diagnostic evaluation with medical services)?
With advancements in artificial intelligence (AI) and augmented intelligence enabled healthcare, the American Medical Association provided guidance outlined in Appendix S taxonomy for describing and classifying various AI applications. This article will help coders understand the AI taxonomy.
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.
Our experts answer questions about medical decision-making, locating procedure codes, and coding a revision of a unicompartmental knee arthroplasty to a total knee arthroplasty.
Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM , walks through the evolution of sepsis definitions that reflect the growing sophistication in our understanding of how the body responds to infection. Understanding the history not only helps contextualize definition variations in provider documentation but also has important implications for coding and reimbursement.
Our experts answer questions on organizing clinical validation queries, the difficulty of diagnosing skin failures, and establishing an organizational definition of sepsis.
We are just entering summertime and meteorologists are already warning about increased heat indexes all over the country. Staying hydrated is important advice because serious maladies can take place when the body becomes dehydrated.
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.
Review the FY 2026 ICD-10-CM tabular addenda for codes that you regularly report so you don’t miss additional information that can augment coding through more guidance or alert you to potential pitfalls.
Make sure you incorporate current CMS coding guidance for three preventive services into your workflow and check for denials that might be candidates for an appeal. Review the latest rules for HIV PrEP, hepatitis vaccine, and CRC screens.
Pain management providers primarily perform radiology services from the diagnostic imaging and radiologic guidance sections of the CPT code book, so specialty coders must know when these services can be separately reported and their documentation requirements. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
We are just entering summertime and meteorologists are already warning about increased heat indexes all over the country. Staying hydrated is important advice because serious maladies can take place when the body becomes dehydrated.
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.
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.
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.
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.
CMS developed medically unlikely edits (MUE) as a way to limit the number of times a particular service is allowed to be billed by a single provider to a single patient on any given date of service. This article explains how MUEs can be used to stop errors. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Clients who participated in court-ordered assisted outpatient treatments (AOT) displayed significant improvements across several outcome measures, according to a study recently published in Psychiatric Research and Clinical Practice.
With advancements in artificial intelligence (AI) and augmented intelligence enabled healthcare, the American Medical Association provided guidance outlined in Appendix S taxonomy for describing and classifying various AI applications. This article will help coders understand the AI taxonomy.
When a physician requests a consult from another physician, how can medical coders tell if the conversation counts toward the data review column in the medical decision-making table? This article provides guidance on when to count those conversations.
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.
