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.
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?
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.
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.
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.
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?
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.
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.
Next year’s CPT manual will include new surgical implants to address knee pain and heart failure, repair diaphragm hernias, and excise pharyngeal neoplasms.
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.
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 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.
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.
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.
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.
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.
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.
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.
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...
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.
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?
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.
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.
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.
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.
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.
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.
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.
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.
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 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.
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?
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.
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.
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.
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?
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.
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.
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.
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.
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.
Rule changes regarding cellular tissue–based products restructured Medicare’s reimbursement strategy for these products. This article covers some related challenges.
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.
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.
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.
While you and your team prepare for the new ICD-10-CM codes that will go into effect October 1, make sure you’re also ready for changes to coding instructions for existing codes.
An angiography is a surgical intervention involving the vessels. In angiography procedures, catheters are manipulated into the body to the site of the procedure, dyes are injected, and images are taken.
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.
Arthroscopic knee surgery allows orthopedic surgeons to inspect the inside of the joint and make a variety of repairs without having to perform open surgery. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Rule changes regarding cellular tissue–based products restructured Medicare’s reimbursement strategy for these products. This article covers some related challenges.
CMS recently published the fiscal year 2027 ICD-10-CM code set for discharges and patient encounters occurring from October 1, 2026 through September 30, 2027.
Practices and revenue cycle management companies that report obstetric services must be ready to report under the new CPT guidelines for maternity care services by September 1, according to John Horton, MD, FACOG, vice chair of the committee on health economics and coding for the American College of Obstetrics and Gynecology.
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.
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.
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.
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?
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.
An angiography is a surgical intervention involving the vessels. In angiography procedures, catheters are manipulated into the body to the site of the procedure, dyes are injected, and images are taken.
An outpatient care model designed to serve high-cost Medicaid patients was found to significantly reduce healthcare spending, hospital admissions, and emergency department visits, according to a study published in The American Journal of Managed Care.
A coding audit may be conducted by internal staff or external entities, typically representing the insurers paying for the care. When planning to implement a coding auditing program, the type of reviews, focus areas, and review frequency must all be taken into consideration. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
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.
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.
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.
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.
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.
Our experts answer questions on assigning ICD-10-CM P codes versus Z codes for newborn conditions, using artificial intelligence to improve documentation and coding workflows, and coding postsurgical malabsorption.
To capture revenue for medically necessary E/M visits and avoid overpayments, your staff must understand when they should and should not use modifiers -24 and -57.
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.
Preventive care is a system of tests and treatments designed to keep healthy people healthy. These services include the administration of immunizations and vaccines, as well as counseling for smoking cessation and nutritional guidance
The Office of the Inspector General announced it is launching a new audit of evaluation and management services billed on the same day as minor procedures.
Hospitals are seeing an increasing number of clinical validation denials that are frequently linked to documentation that does not fully describe the clinical severity of the patient’s condition, even though the documentation technically meets coding requirements. One helpful way to approach this issue is by recognizing inpatient severity drivers—such as physiological instability, organ dysfunction, and treatment intensity—in order to understand the true severity of illness in hospitalized patients.
Preventive care is a system of tests and treatments designed to keep healthy people healthy. These services include the administration of immunizations and vaccines, as well as counseling for smoking cessation and nutritional guidance
In a world full of denials, sometimes the best thing you can be is a denials specialist. However, only 11.66% of respondents to the 2025 ACDIS CDI Salary Survey reported that their department included a CDI denials specialist role.
Cerumen, or more commonly referred to as earwax, is made by the body to protect the ears. Cerumen has both lubricating and antibacterial properties against bacteria, fungi, and water. Code assignment for cerumen removal is based on whether the cerumen is impacted. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The COVID-19 pandemic kickstarted a shift in surgical care from the inpatient to outpatient setting due to elective surgeries in hospitals being suspended. The popularity of outpatient surgeries after the pandemic continued to grow, according to a study published in Medical Care Research and Review.
