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.
When is a procedure coded as a biopsy and when is it coded as something else? The right code depends on the purpose of the procedure. The distinction between a biopsy and another procedure is not always clear.
ICD-10-CM coding guidelines instruct providers to report a code through the entire fracture healing process—changing only the seventh character to signal the stage of healing. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Wound care claims are incredibly complex, and they often involve extensive medical histories, multiple diagnoses, and procedures that require detailed documentation to support proper code selection. Even a seemingly minor omission or ambiguity in the documentation could make all of the difference.
Early dose adjustments for individuals undergoing methadone treatment in outpatient settings were associated with improved treatment retention, according to a study published in PLOS Medicine.
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.
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.
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.
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?
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.
Train your staff on the first batch of medically unlikely edits for CPT codes that went into effect January 1, 2026, along with new edits that just went into effect on April 1.
A greater telemedicine uptake among mental health specialists did not result in improved access to care for patients in communities with specialist shortages, according to a study published in JAMA Open Network.
The difference between straightforward and complex cases is now one of the main factors for coding lower endovascular revascularization. Find out how to document and report services with the new code set.
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.
In an effort to streamline the query process and ensure each missive adheres to stringent compliance standards, many programs now rely on templates that coding and CDI professionals can customize for the specific query opportunity at hand. To explore this topic further, ACDIS asked members of the 2025/2026 CDI Leadership Council to share their thoughts on query templates.
Radiation oncology is a specialty utilizing radioelements either externally or internally to treat medical conditions such as cancer. This article serves as a primer for coding radiation oncology services.
