Q: Why is it necessary for coders, CDI professionals, and providers to align documentation and coding for substance-related disorders when applying both the DSM-5 and ICD-10? How does this impact risk adjustment and HCC capture?
Q: In the 2026 ICD-10-CM update, in the neoplasm chapter there are some added specific codes for inflammatory neoplasm of the breast. How do those differ from other types of breast cancer?
Q: The 2026 ICD-10-CM code update, effective October 1, 2025, has new codes for flank tenderness (R10.8A-) and flank pain (R10.A-). What's the difference between pain and tenderness?
Our experts answer questions about diabetes mellitus in remission, percutaneous versus endoscopic discectomies, and complicated and uncomplicated problems.
Our experts answer questions on better coding and CDI collaboration for escalation processes and AI implementation, queries for undocumented diagnoses and cause-and-effect relationships, and codes for hemorrhages as surgical complications.
Q: When a diagnosis is clinically evident but not yet documented or there is uncertainty about a cause-and-effect relationship between related conditions, would queries be outlined similarly to other types of queries or include different information?
Q: Are there solutions for having better coding and CDI collaboration? How might this help teams with escalation processes and implementation of AI programs?
Our experts answer questions about independent historians, the number and complexity of problems addressed at an encounter, and counting discussion of management.
Q: What if a provider sends a summary of their visit with a patient to the patient’s primary care provider. Is this considered a “discussion” of patient management?
