From concussions and cerebral contusions to complex intracranial hemorrhages and traumatic brain injuries, major head injuries encompass a wide spectrum of clinical presentations and outcomes. Because of their complexity and potential for lasting impact, complete and compliant ICD-10-CM coding is essential to reflect the full clinical severity of these conditions. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Due to all of the possible scenarios that come with a pregnancy, the reporting of ICD-10-CM diagnosis codes must reveal the specific risks patients have so that procedures, services, and treatments can all be supported. Follow Shelley C. Safian, PhD, MAOM/HIM/HI, RHIA, CCS-P, COC, CPC-I, as she outlines best practices for specifically reporting high-risk pregnancies.
Addressing the reliability of documentation, coding, and clinical reasoning underlying PSI flags is not simply a clinical safety imperative; it is a strategic business imperative. Priscilla Marlar, MHA, CSSBB, CPHQ, and John W. Cromwell, MD, suggest that achieving high reliability in quality data integrity starts with understanding the nuances of clinical documentation language and how those nuances are translated by CDI and coding teams into hospital billing codes.
The CPT manual includes many types of biopsies: fine needle aspiration (FNA), core needle, and skin (tangential, punch, and incisional). This article focuses mainly on FNA biopsies and its complicated guidelines, while also touching on core needle biopsies.
The 2026 Outpatient Prospective Payment System final rule isn’t for the faint of heart. CMS finalized many of the major changes from the proposed rule, although the agency did pull back on certain key areas. With big shifts in compliance and reimbursement taking effect, coders have their work cut out for them.
Emergency department visits resulting in outpatient treatment increased sharply, while visits leading to inpatient admission did not—particularly among Medicaid patients—according to research recently published in JAMA Health Forum.
