The measles outbreak is racing through the United States and quite possibly your own healthcare facility. In 2025, a total of 2,289 measles cases were reported in the United States. As of October 16, 2026, there have been 4,410 cases reported in 2026.
CMS is planning major reimbursement shifts for outpatient hospital services, according to the 2027 Outpatient Prospective Payment System (OPPS) proposed rule.
Outpatient social care interventions may strengthen outcomes for children and their families, according to a scoping review published in Academic Pediatrics.
Ensure your team is aware of the latest key updates to the Ambulatory Surgical Center (ASC) Payment System that went into effect on October 1, 2026, which includes changes to codes for surgical procedures, skin substitute products, and drugs, biologicals, and radiopharmaceuticals. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Congenital heart defects, the most common type of birth defect, are among the most clinically significant anomalies in neonatal care. Bobbie Vannatter, MHA, RHIA, CCS, CDIP; Andrew Puckett, DNP, RN, NI-BC; and Vitality Shalumov, RN, BSN, CCDS, reviews selected neonatal congenital cardiac conditions and highlights key documentation considerations that influence coding and representation of severity.
Diagnosis-related group downgrades result from a mix of insufficient or incomplete documentation, coding errors, and diagnoses that lack clinical validation. When higher-acuity diagnoses designated as MCCs or CCs are removed, the case may be reassigned to a lower-paying DRG, resulting in a loss of revenue. Follow Nancy Reading, BS, CPC, CPC-P, CPC-I, as she discusses the challenges of denial reviews conducted by third-party payers and proactive strategies to prevent and manage denials.
At the recent public ICD-10 Coordination and Maintenance Committee Meeting, the Centers for Disease Control and Prevention National Center for Health Statistics discussed 23 proposals involving procedure code topics. Discover some of the updates being considered for implementation on October 1, 2027.
Q: How do the clinical consequences of measles and rubella influence ICD-10-CM code selection, particularly when coding specific complications, congenital rubella syndrome, and infections documented without complications?
Because third-degree burns are a severe injury that destroys the epidermis and dermis and may extend into the underlying subcutaneous tissue, accurate coding depends on clear documentation of burn depth, anatomical site, and total body surface area. Learn how to navigate the fundamentals of ICD-10-CM code selection and sequencing guidelines for third-degree burns, including how to prioritize burn severity and account for multiple injury sites. Note : To access this free article, make sure you first register if you do not have a paid subscription.
New research has found that outpatient follow-up after psychiatric hospitalization among patients with first-admission schizophrenia was associated with a significantly lower risk of readmission, according to a study published in Frontiers in Psychiatry.
Laboratory services are often overlooked as potential suspects for fraud because they are typically not considered high-cost services. But the sheer volume of laboratory services billed more than compensates for their low cost. These charges represent hundreds of millions in healthcare spending.
Practices that treat conditions such as carpal tunnel syndrome and osteoarthritis of the knee must review a new uniform policy that covers a variety of painful chronic conditions. Start now by training staff and reaching out to patients who are no longer covered.
CMS recently released a transmittal regarding the quarterly updates to the OPPS. The transmittal, which was originally published internally, was republished for the public regarding updates that went into effect on October 1. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
As coding teams collaborate across regions and contribute to shared quality and artificial intelligence evaluation initiatives, a common framework for measuring coding quality becomes essential. Without common evaluation principles, coding decisions may be difficult to compare, benchmark, or use for AI evaluation. Shera Stack, MSN, RN, CRC, and April Russell, MBA, CCDS-O, COC, CPC, CPC-P, CRC, consider how a common approach built around agreement, accuracy, defensibility, and truth provides the foundation for meaningful quality assessment.
Terry Tropin, MSHAI, RHIA, CCS-P, focuses on the less extensive changes of the fiscal year 2027 ICD-10-CM update for conditions that received only a handful of new codes but are nonetheless important for accurate and specific code assignment. Although these additions may be easy to overlook among the larger expansions to the code set, they provide new opportunities to capture conditions and clinical circumstances with greater precision.
Q: How can queries play a role in clarifying malnutrition and cachexia diagnoses while ensuring the patient’s condition is reflected in the medical record accurately for proper coding?
Hepatic encephalopathy is a neurologic complication of severe liver disease in which impaired liver function allows toxic substances that are normally metabolized and eliminated by the liver to accumulate in the bloodstream and reach the brain. For coders, understanding the relationship between hepatic encephalopathy, the underlying liver disease, presence of a coma, and liver transplant complications is essential for accurately capturing the patient’s clinical picture and assigning the most appropriate ICD-10-CM codes. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Three newly released compliance audits highlight significant gaps between high-risk diagnosis codes submitted for Medicare Advantage risk adjustment and the medical records supporting those diagnoses. Across the three organizations, OIG found that 533 of 700 sampled enrollee-years lacked sufficient medical-record support for certain submitted diagnosis codes and estimated approximately $202.2 million in overpayments.
Q: How should a coder handle the documentation and coding of a fragility fracture when the underlying cause, such as osteoporosis, has not been clearly established?
CMS recently published the fiscal year 2027 ICD-10-CM Official Guidelines for Coding and Reporting to accompany the ICM-10-CM update, effective October 1. Coders should note the clarifications and revisions added to several areas of the guidelines, specifically as it relates to sepsis, cancer treatment, hypertension, genetic disorders, and Z codes.
Pediatric coding requires a fundamentally different lens than adult coding, as children represent a uniquely complex population with evolving physiology, age-dependent clinical norms, congenital influences, and a heavy reliance on caregiver-reported history. With this in mind, Renee Beus, MSN, RN, NCSN, outlines why pediatric coding cannot always follow adult frameworks, highlights common documentation pitfalls, and identifies what organizations must prioritize when building reliable pediatric coding and CDI programs.
Lysosomal storage disorders are a group of rare, inherited metabolic disorders caused by genetic mutations that affect the normal function of lysosomes, or the structures within cells that contain enzymes responsible for breaking down and recycling various substances, including fats, sugars, proteins, and other cellular materials. Review some of the major categories in which commonly encountered lysosomal storage disorders are classified. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Hypertensive heart disease results from untreated or under-treated hypertension, causing a range of physiologic changes affecting the left atrium, left ventricle, and coronary arteries. Nancy Reading, BS, CPC, CPC-P, CPC-I, delves into the progression of hypertension to heart failure and shows how accurate code assignment and sequencing of the two conditions rely on the reason for admission and the relationships established among the patient’s conditions as documented by providers.
Practices that perform allergy testing take note: A uniform allergy diagnostic testing policy for Medicare Part B patients will go into effect in 38 states as soon as September 27.
Artificial intelligence (AI) is changing medical coding workflows. AI-assisted technology can help coding professionals work more efficiently. But there is an important distinction between identifying a possible code and determining whether that code should actually be reported.
The AMA recently announced that the 2027 CPT code set includes 299 new codes, 74 revisions, and 80 deletions coming to a variety of services. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
A TIA is typically a short-lived transient event that results in no permanent tissue damage or residual neurologic deficits. On the other hand, a stroke results from either a vessel blockage or a hemorrhage, causes some variety of tissue damage, and may leave residual neurologic deficits. Follow Nancy Reading, BS, CPC, CPC-P, CPC-I, as she explores the differences between these two conditions.
A report issued by the Centers for Disease Control and Prevention found that 15.2% of U.S. pregnant women reported current alcohol consumption during the past 30 days. The report, which examined 2021–2024 data from the Behavioral Risk Factor Surveillance System, also found that 4.9% of pregnant women reported binge drinking and 2.2% reported heavy drinking.
Q: What clinical factors distinguish acute skin failure from a pressure injury, and how should the two conditions be approached from an ICD-10-CM coding perspective?
Society is working hard to eliminate or reduce the stigma associated with the need for psychological healthcare services. Some patients require more intensive treatment and focused care, and the services provided during these inpatient stays are reported using codes from ICD-10-PCS, specifically those found in Section G. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, provides an in-depth review of this section and the many services that can be reported.
Identifying secondary diagnoses is an important part of accurately reflecting the patient’s overall condition and the care provided during an encounter. While the primary diagnosis represents the main reason for the patient’s visit or admission, secondary diagnoses capture additional conditions that require attention or have an impact on the patient’s care. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Less than one-half of adults discharged from emergency departments for diabetes-related encounters obtain outpatient follow-up care within 30 days, according to a recent study published in the Journal of General Internal Medicine.
Next year’s CPT manual will include new surgical implants to address knee pain and heart failure, repair diaphragm hernias, and excise pharyngeal neoplasms.
Q: When coding endoscopic procedures, some CPT codes have multiple procedures bundled in a single code. How do coders report when one of the procedures isn’t done?
Prior to the 1970s, there was not an objective method of evaluation and management documentation, which led to physicians making unscientific decisions about patient treatment. Now, one of the general ways that providers document their services is the SOAP format, which helps them organize their thoughts for a patient encounter. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The fiscal year 2027 update to the ICD-10-CM code set includes new, deleted, and revised codes, as well as hundreds of changes to “Excludes” notes and “Code Also” indications. This code set was produced to show greater coding specificity by publishing codes with greater clinical specificity.
The range of evaluation and management services and ways to bill them continues to expand. But with more billing opportunities comes more confusion about work that can and cannot be billed.
Building a strong relationship between coding and CDI begins with the training and education of new professionals. Learn how organizations are using shared education, coding resources, concurrent coding, and ongoing collaboration to close knowledge gaps and help coding and CDI teams resolve DRG mismatches, navigate complex coding questions, and improve documentation and coding accuracy.
The ICD-10-PCS updates for fiscal year 2027 were released in June, and its new codes will be effective Oct. 1, 2026. A majority of the modifications involve new qualifier values for generic devices, but in some cases, new values were added to report brand-named devices. Terry Tropin, MSHAI, RHIA, CCS-P, focuses on the changes to the New Technology section.
Beginning in 2027, services for antepartum care, labor management, delivery, and postpartum care will be coded separately. The old global approach to billing obstetric care was intended to simplify billing, but it no longer reflects the variation and complexity of care across the phases of pregnancy.
The ICD-10-PCS updates for fiscal year 2027 were released in June, and its new codes will be effective Oct. 1, 2026. A majority of the modifications involve new qualifier values for generic devices, but in some cases, new values were added to report brand-named devices. Terry Tropin, MSHAI, RHIA, CCS-P, focuses on the changes to the Medical and Surgical, Administration, Extracorporeal or Systemic Assistance and Performance, and Imaging sections.
Our experts answer questions on distinguishing cachexia from malnutrition for accurate coding, navigating clinical uncertainty and coding for acute skin failure and pressure injuries, and unpacking the fifth universal definition of MI.
Thyroid disorders challenge outpatient hospital coders because the record often contains symptoms, laboratory values, medications, imaging findings, and surgical history before it contains a clear final diagnosis. Those clues can help a coder understand the encounter, but they do not authorize the coder to diagnose the patient.
Congenital heart defects are commonly encountered chronic conditions in pediatric coding and documentation, yet their presence alone does not ensure they are appropriately reported or fully understood within the clinical context of an encounter. Jenny Esper, RHIA, CCS, CDIP, CCDS, tackles the challenges of determining when a CHD is relevant to the admission and whether the documentation accurately reflects its clinical significance for proper coding.
Understanding the clinical findings associated with quadriplegia is an important first step in determining how the condition should be reported. After reviewing the causes and effects of quadriplegia and reportable ICD-10-CM codes for the condition, this article will dive into key physical examination findings and documentation considerations that can help further guide accurate code selection. Note : To access this free article, make sure you first register if you do not have a paid subscription.
The prevalence of healthcare-associated infections in U.S. hospitals declined between 2015 and 2023, according to a Centers for Disease Control and Prevention survey published recently in The New England Journal of Medicine . The findings show continued progress in reducing infections acquired during hospital care, although researchers noted that the overall burden of HAIs persist.
Q: What are the key characteristics of cachexia versus ASPEN-defined malnutrition, and what ICD-10-CM codes are available for reporting each condition?
The ICD-10-PCS updates for fiscal year 2027 were released in June, and its new codes will be effective Oct. 1, 2026. A majority of the modifications involve new qualifier values for generic devices, but in some cases, new values were added to report brand-named devices. Terry Tropin, MSHAI, RHIA, CCS-P, focuses on the changes to the New Technology section.
The new ICD-10-CM code for cannabis hyperemesis syndrome improved clinical recognition of the condition, according to a new Centers for Disease Control and Prevention report. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Most veterans receiving Veterans Health Administration outpatient care for major depressive disorder are receiving their recommended treatment, but a growing proportion aren’t, according to a recent study published in JAMA Network Open.
CMS intends to introduce multiple new codes next year, according to the proposed 2027 Medicare Physician Fee Schedule. The agency is considering codes for advance care planning services by clinical staff, assessment and treatment of patients who have a reaction to a vaccination, and speech-language services for pediatric patients.
Thyroid disorders challenge outpatient hospital coders because the record often contains symptoms, laboratory values, medications, imaging findings, and surgical history before it contains a clear final diagnosis. Those clues can help a coder understand the encounter, but they do not authorize the coder to diagnose the patient.
With insight from Lynette Byerly, BSN, RN, CCDS, CCS, coders can discover how CDI specialists bridge the clinical world to the realm of coding and reporting, especially when pediatric conditions are not always easily reportable.
A diagnosis of systemic lupus erythematosus is only the starting point. Accurate ICD-10-CM coding requires careful attention to the provider's documentation, including whether the lupus is drug-induced, whether specific organ or system involvement is documented, and whether additional codes are required. Note : To access this free article, make sure you first register if you do not have a paid subscription.
A newly released Office of Inspector General report estimates that Medicare Advantage organizations may have received nearly $462 million in improper payments after submitting unsupported acute stroke diagnosis codes to CMS. The findings highlight ongoing concerns about documentation quality and diagnosis validation in risk adjustment reporting.
The ICD-10-PCS updates for fiscal year 2027 were released in June, and its new codes will be effective Oct. 1, 2026. A majority of the modifications involve new qualifier values for generic devices, but in some cases, new values were added to report brand-named devices. Terry Tropin, MSHAI, RHIA, CCS-P, focuses on the changes to the Medical and Surgical, Administration, Extracorporeal or Systemic Assistance and Performance, and Imaging sections.
HCPro invites medical coding professionals to take part in the 2026 Coding Salary Survey. This is your chance to see how your salary, credentials, and role stack up against your peers nationwide. The...
Expiring eviction moratoriums were associated with an increase in outpatient visits for serious mental illness, according to a study published in JAMA Health Forum.
Hospitals are mandated to separately bill HCPCS Level II codes. This longstanding guidance was recently reiterated by two Medicare Administrative Contractors who have published articles on their websites about this specific instruction.
Q: What are some red flags associated with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) that might trigger payer audits?
Beginning January 1, 2027, services for antepartum care, labor management, delivery and postpartum will be coded separately. The old global approach to billing obstetric care was intended to simplify billing, but it no longer reflects the variation and complexity of care across the phases of pregnancy.
In May 2026, outpatient volumes declined significantly month-over-month and year-over-year in comparison to inpatient admissions, according to a report by Strata Decision Technology. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
AI is no longer a distant concept in medical coding and health information management; it is already part of daily work. For many professionals, daily encounters with AI bring a mix of curiosity, caution, and concern.
Our experts answer questions on identifying cerebral edema and brain compression in the medical record, recognizing when documentation drives diabetes coding, and utilizing photos in queries.
You’ll select a modifier and receive a pay boost, one that’s amplified for eligible accountable care organization participants, if CMS goes through its plan to replace patient trust code G2211 with two modifiers.
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.
As if clinically validating sepsis wasn’t complicated enough, adding in the inherent complexity of pediatric health makes reviewing for this diagnosis a challenge. Discover how CDI teams and programs started their pediatric reviews and implemented sepsis education, used query templates and technology, established clinical definitions, and worked with providers and other departments such as coding teams to ensure the diagnosis that is most reflective of the patient’s condition is documented and coded.
Accurately telling the patient’s story requires a thorough review of the entire medical record to identify all conditions that were addressed during the encounter, whether directly or indirectly, by the provider.
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.
Train your coding and clinical teams to think like an auditor before you report modifier -25. Improper payments associated with the modifier have triggered more audits and a variety of attempts to detect and recoup improper payments or stop payments from being issued in the first place.
CMS published the calendar year 2027 Medicare Physician Fee Schedule (MPFS) proposed rule with policies and code changes affecting physician reporting. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
AI is no longer a distant concept in medical coding and health information management; it is already part of daily work. For many professionals, daily encounters with AI bring a mix of curiosity, caution, and concern.
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.
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.
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?
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: A patient is in the office today being seen for abdominal pain six days post-op of removal of a benign tumor. After ultrasound, cholecystitis is diagnosed and the patient is scheduled for surgery the next day. Is it appropriate to use modifier -24 in this case?
Established in 2000, the inpatient-only list has served as a catalog of procedures that can only be reimbursed by Medicare when performed in the inpatient setting. However, thanks to technological advancements and new surgical techniques, many of these services can now be performed in hospital outpatient departments and ambulatory surgical centers.
Early outpatient follow-up was not associated with differences in hospital-free survival or risk of decline in health-related quality of life among older adults after acute myocardial infarction, according to a retrospective study published in the Journal of Hospital Medicine.
Accurately telling the patient’s story requires a thorough review of the entire medical record to identify all conditions that were addressed during the encounter, whether directly or indirectly, by the provider.
The 2027 OPPS and ambulatory surgical center proposed rule includes a policy that aims to expand CMS’ method of controlling unnecessary increases in the volume of outpatient services. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
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.
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.
Kelly Rice, MSHI, BSN, RN, CCDS, CDIP, CCS, CRC, details how to differentiate and document between acute pulmonary insufficiency following surgery and acute respiratory failure following surgery. Identifying and discussing common clinical indicators for these diagnoses can help support documentation integrity efforts, reduced denials, and the inappropriate triggering of PSIs.
Our experts answer questions on navigating sepsis coding in an era of conflicting clinical criteria, evaluating abnormal renal function in the clinical record, and addressing payer denials that passed on queries.
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.
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.
