Cardiorenal syndrome refers to acute or chronic dysfunction of the heart or kidneys that causes dysfunction in the other organ. Review ICD-CM coding for heart and kidney failure and the physiological impact that dysfunction in one system has on the rest of the body. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
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.
The severity and length of post-COVID-19 symptoms has been a topic of study almost ever since the pandemic began. In a new study involving patients with significant respiratory disability following hospitalizations for COVID-19, daily supervised pulmonary rehabilitation was associated with significant improvement in exercise tolerance and quality of life.
Quality metrics are complex, and it takes deep knowledge to understand their intricacies. Audrey Howard, RHIA, and Susan Belley, RHIA, CPHQ , describe commonly overlooked documentation elements that can affect quality metrics and outline how to incorporate these elements into an audit workflow.
As the shift to outpatient care has accelerated, likely due to COVID-19, inpatient volumes continue to remain below pre-pandemic levels for hospitals and health systems this year, according to Kaufman Hall’s 2022 State of Healthcare Performance Improvement report.
ICD-10-CM coding for respiratory illnesses requires a solid understanding of clinical indicators and coding guidelines. Review documentation and guidance for reporting acute respiratory distress syndrome, asthma, and pediatric multisystem inflammatory syndrome. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
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.
Lena Wilson, MHI, RHIA, CCS, CCDS , takes a deep dive into the CDI/coding reconciliation process and outlines tips that coders and CDI professionals can apply to improve this process.
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.
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.
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.
