Coding and billing professionals must ensure that medical record information is accurate, up to date, and compliant. In this article, Holly Cassano, CPC, CRC , defines late entries, corrections, and addendums, and explains the proper methods used to alter health records while maintaining Medicare compliance.
Coding for newborn services can be complicated due to detailed examinations and therapeutic treatments performed after delivery. Sarah Nehring, RHIA, CCS, CCDS , breaks down ICD-10-CM coding for newborn encounters and reviews new codes for newborn apnea that took effect October 1.
The terms “admission” and “observation” are often confused. Dawn Valdez, RN, LNC, CCDS, CDIP, distinguishes between these terms and evaluates ICD-10-CM coding for patients who begin in observation and are later admitted to the hospital for more intensive care.
Kathy Shumpert, MSN, RN, CCDS, writes about the evolution of the denials and appeals process at her facility and discusses tactics to improve communications and efficiency.
The ICD-10-CM Official Guidelines for Coding and Reporting provide a roadmap for accurate diagnosis coding. Kimberly Lee, M.Ed., RHIA, CCS-P, unpacks fundamental ICD-10-CM coding concepts.
Our experts answer questions about ICD-10-PCS coding for cardiac catheterizations, reporting COVID-19 vaccination status in ICD-10-CM, and diagnosis coding for reactions to COVID-19 vaccines.
Stroke, or cerebrovascular accident (CVA), is the fifth leading cause of death in the U.S. and the second leading cause of death worldwide, according to the Centers for Disease Control and Prevention. Unpack clinical documentation and ICD-10-CM coding for various types of CVA. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Pregnancy causes changes to the immune system that increase the risk of infection and sepsis during pregnancy, labor, and the puerperium. Sarah Nehring, BS, RHIT, CCS, CCDS , analyzes ICD-10-CM documentation and coding for sepsis after childbirth.
A recent medical record review published in the Journal of the American Medical Association Network Open found that between October 1, 2021, and January 31, 2022, providers used ICD-10-CM code U09.9 (post-COVID-19 condition, unspecified) to identify a multitude of post-acute conditions brought on by COVID-19.
Social determinants of health ICD-10-CM codes have become more of a hot topic in the CDI world over the past few years. Review guidance for reporting personal circumstances such as income, wealth, and education that impact health and wellbeing.
A coder’s practice should check its telehealth claims against the information in the recent Office of Inspector General data brief on telehealth services, healthcare attorneys advise. Julia Kyles, CPC, reviews the September 2 report, which contains findings and program integrity measures for telehealth services.
The 2023 update to the ICD-10-CM code set includes over 60 new codes for intracranial injuries with loss of consciousness, status known. This article covers codes from the 2023 ICD-10-CM update that pertain to traumatic injuries of the brain, specifically the cerebrum, cerebellum, and brainstem. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS recently published Transmittal 11594 , outlining HCPCS codes for drugs that received pass-through status, new proprietary laboratory analysis (PLA) codes for tests, code revisions for pharmaceutical drugs, and skin substitute product codes, all of which became effective October 1.
Flail chest is the most severe type of blunt traumatic chest injury and is likely the most common serious thoracic injury. Debbie Jones, CPC, CCA, explains the symptoms, diagnostic process, and guidelines associated with reporting flail chest.
Coders must be familiar with ICD-10-CM reporting guidelines for common neurological conditions. This article unpacks recent updates to the nervous system chapter of ICD-10-CM including 14 new codes for autonomic conditions and fatigue syndromes. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
A recent review of inpatient medical records published in the Journal of the American Medical Association Network Open from 463 hospitals found significant increases in pregnancy-related complications and maternal death during the COVID-19 pandemic.
