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.
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.
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.
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?
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.
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?
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.
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.
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.
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.
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.
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.
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.
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?
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 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.
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.
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?
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.
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.
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.
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.
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.
Neonatal intensive care units provide care and additional medical attention for neonates who might be born prematurely, with low birthweight, with a medical complication, or with a congenital anomaly. Follow Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, as she delves into common services performed in these units and how they are reported with ICD-10-PCS codes.
Review a study published in the Journal of the American Medical Association that suggests respiratory syncytial virus poses a far greater long-term health risk to adults in the months following hospitalization than previously understood due to increased risks of complications for myocardial infarction, stroke, chronic obstructive pulmonary disease exacerbation, congestive heart failure exacerbation, and arrhythmia.
When planning to implement a coding auditing program, the type of reviews, focus areas, and review frequency must all be taken into consideration, as each facet impacts the level of staffing required to conduct the reviews. Coding auditors should pick a few key elements to review, and the items should be of importance to your organization. Ideally, the topics will focus on issues that are frequent or require reassurance. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Immunoglobulin G4-related disease is a chronic immune-mediated fibroinflammatory disorder that often manifests with tumor-like masses and/or painless enlargement of multiple organs. Shontia Leon-Guerrero, CPC, CEDC, CEMC, CPC-I Educator, explores the general manifestations of the disease, its signs and symptoms, as well as key documentation tips and a coding scenario.
Insurance companies are increasingly challenging the translation from the medical record to prebill coding, making the financial impact of denials and downgrades one of the most pressing issues facing health systems today. Given the wide-ranging harm occurring from delayed and reduced reimbursement, Dawn Valdez, RN, CCDS, CDIP, highlights how coders and CDI specialists can play a key role in decreasing denials and downgrades as well as successfully disputing these actions.
Coders and billers may struggle to understand what the term medical necessity really means. Unfortunately, these two words can easily lead to misinterpretation and misunderstanding of what needs to be clearly communicated in a variety of healthcare areas. Learn common definitions of medical necessity, report types utilized in inpatient settings, and a query process in case more clinical detail is required. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Q: Why is pediatric malnutrition frequently underdocumented, and how can collaborative workflows improve documentation and coding accuracy as well as reduce queries?
A diagnosis of cancer becomes a pre-existing condition that will follow a patient for the rest of their life, but clinical records do not always provide the level of detail required to work within the framework set forward in the coding rules when it comes to reporting active neoplasms from personal history. Nancy Reading, BS, CPC, CPC-P, CPC-I, explores ICD-10-CM guidelines for such neoplasm scenarios.
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 79.0 years in 2024 while the mortality rate decreased by 3.8% to 722.1 deaths per 100,000 of the standard population in 2024. Also determined were leading causes of death.
From concussions and cerebral contusions to complex intracranial hemorrhages and traumatic brain injuries, major head injuries encompass a wide spectrum of clinical presentations and outcomes. Because of their complexity and potential for lasting impact, complete and compliant ICD-10-CM coding is essential to reflect the full clinical severity of these conditions. Note : To access this free article, make sure you first register if you do not have a paid subscription.
A prognostic study published in the Journal of the American Medical Association raises concerns that AI models designed to predict hospital outcomes may appear far more accurate than they truly are due to a subtle but serious methodological error known as label leakage.
Due to all of the possible scenarios that come with a pregnancy, the reporting of ICD-10-CM diagnosis codes must reveal the specific risks patients have so that procedures, services, and treatments can all be supported. Follow Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I, as she outlines best practices for specifically reporting high-risk pregnancies.
Addressing the reliability of documentation, coding, and clinical reasoning underlying PSI flags is not simply a clinical safety imperative; it is a strategic business imperative. Priscilla Marlar, MHA, CSSBB, CPHQ, and John W. Cromwell, MD, suggest that achieving high reliability in quality data integrity starts with understanding the nuances of clinical documentation language and how those nuances are translated by CDI and coding teams into hospital billing codes.
Q: How do ICD-10-CM T codes work together with Z, F, and Y codes to fully capture drug-related conditions, and in what order should these codes be sequenced?
Q: What are the most common reasons postpartum hemorrhage is documented and coded inconsistently, and how can coders and clinicians help address these issues?
Correctly coding an aneurysm depends on the type and location, the specific vessels involved, and the presence or absence of associated complications such as ruptures. Each of these elements directly impacts code assignment, making detailed clinical documentation essential to ensure the conditions are accurately represented in the medical record. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Coding for spinal fusions can be very complex, with many different devices and approach options as well as the procedure requiring more than one code. Terry Tropin, MSHAI, RHIA, CCS-P, walks through the New Technology section of the ICD-10-PCS along with other less common sections to find where appropriate spinal fusion codes can be located.
CMS announced it is adding 80 new procedure codes to the fiscal year 2026 ICD-10-PCS code set, available for discharges occurring from April 1 through September 30, 2026. This is in addition to the 156 new codes that went into effect on October 1, 2025. Only two codes will be deleted.
Collaboration can take many forms depending on the needs of an organization, but Leah Ainsworth, BSHIIM, RHIA, CDIP, CCS, CCDS, shows how her department is just one of many to make coding and CDI work hand in hand to create meaningful impacts and ensure accuracy.
