New FY22 Code: Non-Traumatic Cardiac Injury

With the current ICD-10-CM code set, there is no specific code corresponding to non-traumatic myocardial injury. Given the high severity of illness typical of patients with non-ischemic myocardial injury, appropriate classification of these patients is paramount in terms of aligning appropriate diagnostic and treatment strategies while avoiding inappropriate approaches that would otherwise be suggested by…

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New FY22 Code: Gastric Intestinal Metaplasia

Intestinal metaplasia (IM) occurs when cells in the tissues of the upper digestive tract, often in the stomach or esophagus, change and become more like cells from the intestines. Intestinal metaplasia in the esophagus is also called Barrett’s esophagus. Intestinal metaplasia is more common in people who have chronic acid reflux or gastroesophageal reflux disease (GERD). The…

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FY 2022 ICD-10-CM Updates

Medical Coding

Abnormal Findings on Neonatal Screening Currently there is only a single code to capture any or all types of newborn screenings that may have positive or abnormal results. The American Academy of Pediatrics requested expansion of category P09 Abnormal findings on neonatal screening, to specifically show which screening categories were abnormal. Table 1 shows the…

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The Role of a Physician Advisor

Given the heightened focus on documentation and impacts to healthcare organizations from both a financial and quality perspective, it is imperative that clinical documentation improvement (CDI) leaders implement an effective strategy to develop a physician advisor program. The success of a CDI physician advisor program hinges upon defining the physician advisor’s role. A physician advisor…

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Glasgow Coma Scale – July 2021 Coding Tip

The Glasgow Coma Scale (GCS) is a clinical scale used to measure a person’s level of consciousness after a brain injury. The scoring is determined by three factors: amount of eye opening, verbal responsiveness, and motor responsiveness. The Glasgow Coma Scale has an adult version and a pediatric version. The pediatric version is also composed…

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New FY22 Code: Measurement of Flow in a Cerebral Fluid Shunt

There are currently no unique ICD-10-PCS codes to describe the noninvasive measurement of flow through a cerebrospinal fluid (CSF) shunt. Hydrocephalus is a debilitating neurological disorder that results from the overproduction and/or impaired reabsorption of cerebrospinal fluid (CSF) in the ventricles of the brain. Hydrocephalus affects over 1 million people in the United States alone….

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AKI with ATN CDI Scenario – July 2021

Medical Coding

H&P: Patient presented with shortness of breath and palpitations noted to be in atrial fibrillation and with AKI. Patient with baseline creatinine of 1.1, noted as 1.5 on admission. Give IVF for AKI and monitor labs. Platelets 64, consult Hematology for ITP treatment recommendations PMH: Idiopathic thrombocytopenia purpura (ITP) treated in past with IVIG with…

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