The coding of complications should be based on the documentation in the medical record, the Official Guidelines for Coding and Reporting (OGCR), or both.
Category: Coding Tip
Cancer registry data collection starts with a process known as case-finding or case ascertainment, and it is exactly that, finding cases that must be included in a reporting facility’s cancer registry.
In ICD-10-CM sleep disorders are coded to two different chapters of the codebook depending on the cause.
New for 2020 are Evaluation and Management (E/M) codes to report online digital services. The purpose of these codes is to report physician/qualified health care professionals (QHPs) and nonphysician time spent performing E/M services in response to patient-initiated inquiries within online digital environments such as patient portals.
When coding glaucoma, terms such as primary, open angle, closed angle, primary angle closure, and narrow angle can leave a coding professional confused and frustrated.
Coding Professionals have been working with ICD-9-CM since 1979 and little did they know the codes they assigned would permeate every business process in healthcare.
The key to properly coding hernia procedures is knowing what questions to ask yourself as you read through the patient’s health record.
If you’re embarking on a new journey as a traveling CDI specialist, you’re probably experiencing a variety of emotions, ranging from excitement to nervousness.
Many coders struggle with coding spinal fusion procedures. First, the terminology can be confusing.