Q: A patient has acute renal failure due to dehydration, a history of Type 1 diabetes mellitus causing end-stage renal disease, a kidney transplant two years ago, and chronic kidney disease stage 3a, immunosuppressed by their drugs. How would this be reported in ICD-10-CM?
Managing chronic conditions requires involvement from many parties, making documentation challenging. Assess how to improve documentation and reimbursement for chronic conditions with tips provided by Arta Kelmendi-Doko, MD, PhD . Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Brandi Hutcheson, RN, MSN, CCM, CCDS, CCA , examines the coding and clinical literature on malnutrition and obesity to see how coders can reconcile these seemingly disparate diagnoses.
A Journal of the American Medical Association study found that ICD-10-CM influenza codes accurately represented cases of positive diagnoses in pediatric patients, but their sensitivity was modest.
Hamilton Lempert, MD, FACEP, CEDC, reviews the basics of critical care services in CPT and addresses common reporting questions, such as services that pass midnight, continuous care, and which clinical tasks count toward critical care. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The Food and Drug Administration’s (FDA) emergency use authorization for Pemgarda, a pre-exposure COVID-19 prophylaxis, has led to the release of HCPCS Level II codes for the drug and its administration.
Nancy Reading, RN, CPC, CPC-P , explains how understanding liver disease and its many complications is key to supporting higher-specificity ICD-10-CM coding and reimbursement.
Penny Jefferson, MSN, RN, CCDS, CCDS-O, CCS, CDIP, CRC, CHDA, CRCR, CPHQ , and Mercedes K. C. Dullum, MD, FACS, FACC , describe the advantages of creating CDI programs in outpatient settings and how they can decrease gaps in patient care and improve financial management.
Pressure injuries, which can lead to a patient safety indicator (PSI), require clear documentation and coordination among coding, CDI, and clinical departments. Katherine Siemens, RN, BSN, CMSRN, CCDS , evaluates how poor coordination could result in a PSI being incorrectly reported.
Q: A 64-year-old female bilateral lung transplant recipient presents with aspiration pneumonia, hypoxia, and has immunosuppression from the drugs. How would this scenario be reported in ICD-10-CM?
Despite the expansion of codes that came with the transition from ICD-9 to ICD-10-CM, the majority of codes for inflammatory arthritis were not frequently used in 2015 through 2021, researchers found.
Sarah McDonald, CPC , reviews ICD-10-CM and ICD-10-PCS coding guidelines for the U.S.’ most common orthopedic surgeries: hip and knee replacements. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Merle Zuel, RN, CCDS , explains how healthcare leaders can improve in their roles by understanding all coding and clinical data available and knowing how to analyze it.
CMS published a summary of its first quarter 2024 HCPCS Level II code update application decisions. There were 48 additions, two code definition revisions, and seven discontinuations.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , explains how to report neonatal respiratory failure, including meconium aspiration, failure to thrive, and associated symptoms in ICD-10-CM.
Lynn Anderanin, CPC, CPB, CPMA, CPC-I, CPPM, COSC , covers FAQs she has received, specifically about CPT reporting for arthrodesis, acromioplasty, arthroplasty, arthroscopy, and spinal decompression procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Julia Kyles, CPC , examines the factors of medical necessity required to decrease chance of denials for preoperative E/M visits, including who performs the visit, associated risks, and the patient’s health.
Q: How would a coder report the scenario of an unmedicated diabetic patient with diabetic renal nephrosis and out-of-control blood sugar during an encounter?
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, explains how to report neonatal respiratory failure, including meconium aspiration, failure to thrive, and associated symptoms in ICD-10-CM.
Our experts answer questions about ICD-10-CM coding for diabetic patients with hyperglycemia, CPT documentation requirements for wound sizing, and more.
by Jess Fluegel It is a truth universally acknowledged that a CDI department, in possession of a part-time physician advisor who is already stretched too thin, may be in want of provider engagement...
Tonya Chandler, RHIT, writes about mental health status in youth, clarifies possible contributing factors, and explains how to report mental and behavioral conditions in ICD-10-CM with several case scenarios.
Our expert answers questions about ICD-10-CM sequencing for renal complications after a transplant, reporting malignant neoplasms in transplanted organs, and more.
Pressure injuries, which can lead to a patient safety indicator (PSI), require clear documentation and coordination among coding, CDI, and clinical departments. Katherine Siemens, RN, BSN, CMSRN, CCDS , evaluates how poor coordination could result in a PSI being incorrectly reported.
This article reviews malware basics and covers tips that healthcare employees can implement to avoid cyberattacks that could put protected health information (PHI) at risk.
This article reviews malware basics and covers tips that healthcare employees can implement to avoid cyberattacks that could put protected health information (PHI) at risk.
Educating clinical staff on proper documentation of mechanical ventilation can avoid compliance issues and support accurate reimbursement. This article clarifies the complications of reporting mechanical ventilation in ICD-10-PCS.
CMS’ fiscal year 2025 IPPS proposed rule and fact sheet, published April 10, includes proposals for a 2.6% payment increase, a new bundled payment program, code updates, and other policy changes.
Q: How would the scenario of a previous kidney transplant patient presented with sepsis due to acute pyelonephritis (E. coli), CKD, and immunosuppression be reported in ICD-10-CM?
Sarah McDonald, CPC , examines the ICD-10-CM/PCS coding conventions for symptoms, stages, and treatment of gastroesophageal reflux disease—a commonly diagnosed digestive disorder in the U.S. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Ronald Hirsch, MD, FACP, CHCQM, CHRI , and Valerie A. Rinkle, MPA, CHRI , explore common causes of denial, including prior authorization, missing documentation, medical necessity, and EHR formatting.
CMS proposed hundreds of ICD-10-CM code changes in the 2025 IPPS proposed rule, published April 10, including 252 new codes, 13 revised codes, 36 invalidated codes.
Lynn Anderanin, CPC, CPMA, CPPM, CPC-I, COSC , answers frequent questions she receives from providers pertaining to physician coding for CPT orthopedic services. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Tonya Chandler, RHIT , brings light to the declining mental health in youth, clarifies possible contributing factors, and explains how to report mental and behavioral conditions in ICD-10-CM with several case scenarios.
Kate Siemens, RN, BSN, CMSRN, CCDS , offers tips on how coders and CDI can assess patient safety indicators to improve reporting accuracy and increase quality of care.
The Journal of the American Medical Association (JAMA) published a study that found that high-flow nasal cannula protocols were associated with a 6.1% reduction in ICU admissions among children.
Sarah McDonald, CPC , explains the spinal fusion process and overviews the process of constructing ICD-10-PCS procedure codes character by character. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The pediatric population is smaller and involves different clinical and nuances, but this often-underdeveloped area of coding can be a source of missed revenue if left uninvestigated.
Q: Aside from Coding Clinic , Third Quarter 2005, pp. 19–20, is there any more up-to-date advice on reporting ICD-10-CM diagnoses from physician orders?
Physician coders should watch out for recently implemented edits to codes that debuted January 1 in the quarterly updates to the NCCI files. The latest updates introduce 2,171 new PTP edits and 164 new MUEs.
CMS published its HCPCS Quarterly Update in March, which heralded the sum of 94 HCPCS Level II code additions, discontinuations, and definition revisions. The changes became effective April 1.
Orthopedists perform injections and aspirations to address a range of ailments, but reporting injections can be difficult. This article reviews proper CPT coding for sacroiliac joint injections and joint arthrocentesis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The lack of interaction with remote work has a variety of impacts. Managers must develop strategies for remote onboarding and training, find different ways to measure productivity, and keep employees engaged.
Many CDI professionals are familiar with the saying that, since CDI is “already in the chart,” they can easily pick up a new review lens. The reality, however, is that each new responsibility can put a damper on staff bandwidth and productivity.
