Pressure ulcers are one of the best-known quality-of-care conditions among medical staff, clinical documentation integrity (CDI), and coding professionals. Yet while hospitals often track any skin integrity issues, CDI professionals…
We all lost an hour of sleep when we “sprang forward” this past weekend. This week is National Sleep Awareness Week for 2026. In its 28th year and instituted by the…
When a patient leaves the hospital against medical advice (AMA), the discharge is not only a clinical concern, but it can also create coding and compliance challenges. Ensuring the process…
Continuing our look at areas where we see confusion we will examine the assignment of the long term use codes for anticoagulants versus antithrombotics/antiplatelets. GoodRx.com, in an article titled, “Antiplatelet…
Continuing with our look at areas of coding confusion, let’s today examine pain. According to Medline Plus Magazine from the National Institutes of Health (NIH), pain is the most common…
The Medicare and Medicaid provider auditing process is about to get a makeover in 2025. I am talking about artificial intelligence (AI), which may be more accurate than our auditors,…
While underdosing is no longer a new concept in coding it remains a common area of confusion. Underdosing is when a patient takes less of a medication than is prescribed. …
Legal scholars, practitioners, and other observers have grappled with the legal dimensions of artificial intelligence (AI). As early as 1992, Solum discussed the case for considering AI to be a…
One of the goals of medical coding is documenting encounter notes to the highest degree of specificity. ICD-10-CM had some existing codes for documenting foreign bodies entering through a natural…
In the ever-evolving world of healthcare coding, professionals must stay abreast of the latest updates to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). This dynamic coding system…
While the introduction of new COVID-19 reimbursement rules and regulations have brought on their share of confusion, there is one certainty healthcare organizations can bank on: oversight of incentive dollars…
Medical coders are typically behind the scenes of patient care, analyzing records, selecting codes for billing, and managing patient data. But to Jannifer Owens, a revenue cycle expert with over…
The time to strengthen hospital compliance programs through claim validation is now. According to healthcare finance and information management leaders surveyed by HIMSS Media, clinical documentation and coding were the…
Hospitals have relied on a relatively manual process and retrospective audits for coding compliance, but new technology is streamlining the process, allowing providers to get ahead of denials. Healthcare technology…
The ICD-10 transition is negatively impacting inpatient and outpatient coder productivity at hospitals of all sizes and types, according to survey results from healthcare outsourcing vendor HIMagine Solutions Inc. The…
The CMS has made a concession in the transition from ICD-9 to ICD-10. For one year past the Oct. 1, 2015 deadline, the CMS will reimburse for wrongly coded claims…