Our experts answer questions on overcoming documentation challenges for sepsis, ICD-10-CM coding for infections of devices vs. wound infections as well as class three obesity and/or morbid obesity, and querying physician abbreviations.
Building a team of fully cross-trained coders who are competently able to code all record types is one of a coding manager’s goals. Achieving this goal requires that managers inventory the skills of each coder, identify focused education, and plan for cross-training opportunities.
You may have noticed that people are feeling stressed out throughout the United States. Each individual deals with stress in their own way. Most often, ICD-10-CM diagnosis codes reported for these patients may be a bit vague, especially when you are coding for a primary care physician.
With 50 new ICD-10-PCS codes implemented on April 1, Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , thoroughly reviews the codes to help inpatient coders accurately apply the updates.
One of the most frequent causes of hospital-acquired AKI is acute tubular necrosis (ATN). Improving documentation and coding practices for ATN involves not only recognizing the condition but also realizing the impact of coding ATN versus AKI, addressing common misconceptions in the HIM field, and fostering collaboration among CDI specialists, coding professionals, and providers.
Coders play a crucial role in addressing clinical and coding denials, but they are far from alone in this effort. All HIM professionals are working together to create and implement comprehensive strategies that effectively reduce denials, fostering a unified approach to overcoming these challenges.
Although typically associated with outpatient services due to their use of HCPCS codes, chargemasters are also crucial in inpatient settings, as they serve as the foundation for billing services rendered during a patient’s hospital stay. Learn how inpatient coders can help maintain the financial health of their organizations through the proper understanding of chargemasters. Note : To access this free article, make sure you first register if you do not have a paid subscription.
The Centers for Medicare & Medicaid Services has pulled information on health-related social needs (HRSN), a subset of broader social determinants of health factors, for state Medicaid and the Children’s Health Insurance Program, potentially making it harder for services that address HRSNs to be covered by these affected programs.
Q: A month ago, a patient had undergone an open reduction and internal fixation of a traumatic fracture of the left femur. This afternoon, she was admitted for a severe and deep infection of the left thigh and immediately taken to surgery. An open, wide excisional debridement of the infected skin, subcutaneous tissue, and fascia was carried out, and the internal fixation hardware was removed. Cultures of the fixation pins grew Staphylococcus aureus. Can coders report infections of devices similar to how they would report a wound infection in ICD-10-CM?
The largest barriers and facilitators to screening, documenting, and addressing adverse social determinants of health across United States’ emergency departments have been identified in a recent study published in JAMA Network Open.
Postherpetic neuralgia (PHN) is severe pain caused by damage to the nerves at the area or areas affected by shingles after the rash is resolved. Typically, it is pain that persists four or more months after the initial onset of the rash. For documentation purposes, the physician would need to state which type of PHN the patient has. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
Train new coders to follow CMS’ rules when they find CPT guidance that doesn’t match Medicare’s requirements. This article discusses how the CPT manual’s instructions to report modifier -99 (Multiple modifiers) don’t match instructions from CMS and some Medicare administrative contractors.
Selecting a level of medical decision-making (MDM) is confusing and complicated. In this article, Terry Tropin, MSHAI, RHIA, CCS-P, defines key MDM terms and describes a simplified system for selecting a level of MDM.
One of the most frequent causes of hospital-acquired AKI is acute tubular necrosis (ATN). Improving documentation and coding practices for ATN involves not only recognizing the condition but also realizing the impact of coding ATN versus AKI, addressing common misconceptions in the HIM field, and fostering collaboration among CDI specialists, coding professionals, and providers. Note : To access this free article, make sure you first register if you do not have a paid subscription.
ICD-10-CM official guidelines once stated that if there is conflicting documentation in the health record, the documentation of the attending physician supersedes that of any other provider. With that rule now gone, Cheryl Ericson, RN, MS, CCDS, CDIP , helps clarify who should be determining diagnoses.
Review a study based on ICD-10-CM data from the National Vital Statistics System that shows a decline in U.S. maternal mortality rates from 22.3 deaths per 100,000 live births in 2022 to a rate of 18.6 deaths in 2023.
Research of multiple countries on various continents and with varied complexity of healthcare environments reveals significant disparities in health outcomes and access to healthcare, and a staggering percentage of health outcomes are attributed to social determinants of health. Studying these countries shows differences in how socioeconomic issues are captured in documentation and coded using different patient classification systems, guidelines, and regulations.
Radiologists and providers who implant or program implantable medical devices should review the six new magnetic resonance (MR) safety CPT codes that went into effect January 1, 2025. The codes describe the work involved when a medical implant or metallic foreign bodies create additional risks for an MR exam.
When medical services are rendered, the expectation is that the facility and/or provider will be reimbursed for those services. Sometimes the reality is that a claim will be denied as it “fails to meet medical necessity” by the insurance carrier. It is always in your best interest to appeal all medical necessity denials. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
A recent report from the Brown University School of Public Health compared the average commercial price for low-complexity, low-intensity medical care in New York hospital outpatient departments to the same care provided in non-hospital settings, such as physician offices and ambulatory surgery centers.
You may have noticed that people are feeling stressed out throughout the United States. Each individual deals with stress in their own way. Most often, ICD-10-CM diagnosis codes reported for these patients may be a bit vague, especially when you are coding for a primary care physician.
On November 1, 2024, CMS released its final rule describing calendar year 2025 policies and rates for Medicare’s Outpatient Prospective Payment System and the final rule was published in the Federal Register. This article is a comprehensive overview of all the major highlights, allowing coders to stay informed about key updates and navigate the changes throughout the year.
With the prevalence of diabetes mellitus among the population expected to grow, an overview of the disease may help you keep track of how to code instances of it. This article will cover the different types of diabetes mellitus and a few tips when coding it.
Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS , and Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, CCDS-O , review some of the significant changes to the first quarter of AHA’s 2025 Coding Clinic.
The spectrum of myocardial injury, ischemia, and infarction represents a critical area in cardiology, which Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , explores in detail, integrating information from current clinical guidelines, diagnostic standards, and management strategies.
Practices upped their use of modifier 59 (Distinct procedural service) in recent years, adding nearly 1 million 59-appended claims to the most frequently reported same-day procedural codes.
There were 371 new codes added to the October update of the 2025 ICD-10-PCS code set, but Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , narrows her investigation into the new codes for one particular body system within the Medical and Surgical section: Lower Arteries.
Artificial intelligence is revolutionizing healthcare administration by enhancing efficiency, accuracy, and decision-making across various processes, with medical coding standing at the forefront of this transformation. Understanding AI-driven programs and the evolution of medical coding is essential for coders to thrive in this rapidly changing landscape. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Review a study funded by the National Institutes of Health that has found adults who were hospitalized for a severe infection, such as respiratory infections or sepsis, were twice as likely to develop heart failure years later.
Leveraging tools like clinical decision support (CDS) systems and physician queries can improve patient care and ensure documentation integrity. Yet medical coders need to ensure they use automated guidance without overstepping into clinical decision-making, maintaining the integrity of both documentation and coding while avoiding potential misinterpretations or misrepresentations of a patient’s condition.
Q: Consider a patient who received a hysterectomy two days ago and was later admitted for severe acute abdominal pain around the surgical wound. When the wound was reopened, it was discovered that an instrument had been left in her body. The instrument was removed, and the wound was resutured. How would coders report this situation with ICD-10-CM codes?
There were 371 new codes added to the October update of the 2025 ICD-10-PCS code set, but Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , narrows her investigation into the new codes for one particular body system within the Medical and Surgical section: Lower Arteries.
Treating providers can perform audio-only evaluation and management visits via telephone for patients who are at home thanks to the three-month telehealth extension through to March 31, 2025. But remember to follow the rules for audio-only visits in the final 2025 Medicare physician fee schedule.
With the prevalence of diabetes mellitus among the population expected to grow, an overview of the disease may help you keep track of how to code instances of it. This article will cover the different types of diabetes mellitus and a few tips when coding it.
A recent study published in BMC Public Health, found that patients in Colorado diagnosed with long COVID increasingly sought care from outpatient and specialist visits over hospital and emergency department visits.
This article wraps up our coverage of modifiers commonly used by pain management practices that are required by Medicare and private payers when a CPT procedure code on a claim isn’t detailed enough to precisely tell what service or procedure was provided. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
Q: Patient is a young but quite debilitated and oxygen-dependent female with a complex history and frequent hospitalizations. She currently presents with exacerbation of bronchiectasis secondary to Swyer-James unilateral emphysema, chronic postinfectious bronchiolitis obliterans syndrome following bronchiolitis obliterans in childhood, and superimposed bacterial pneumonia. Her condition is complicated by morbid obesity with a BMI of 42 and severe obesity hypoventilation syndrome with obstructive sleep apnea. How would this diagnostic note be reported in ICD-10-CM?
The spectrum of myocardial injury, ischemia, and infarction represents a critical area in cardiology, which Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , explores in detail, integrating information from current clinical guidelines, diagnostic standards, and management strategies.
Because discrepancies among payers’ diagnostic standards can lead to documentation issues, coding errors, and denials, revenue integrity professionals are encouraged to increase collaboration between CDI, coding, and clinical staff when addressing varying criteria. Discover further how coders play a key role in analyzing criteria, identifying denial trends, and ensuring providers receive proper training and education.
Given the variety and complexity of surgical complications, coders should understand the nuances of differentiating between surgical complications and pre-existing conditions, stay up to date with coding guidelines, and familiarize themselves with ICD-10-CM chapters where complications codes are located. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Review a study published in a recent edition of Health Affairs that discovered which type of hospitals are not evaluating their AI tools internally for accuracy or potential biases and explored whether models developed in-house or by external developers were supported more by local evaluations.
A study published in the Annals of Internal Medicine found that even when patients agreed to be charged for queries sent though a portal, only a tiny fraction of these asynchronous encounters were billed. This article covers why e-visits may be difficult to bill.
On November 1, 2024, CMS released its final rule describing calendar year 2025 policies and rates for Medicare’s Outpatient Prospective Payment System and the final rule was published in the Federal Register. This article is a comprehensive overview of all the major highlights, allowing coders to stay informed about key updates and navigate the changes throughout the year.
