As a clinical documentation integrity (CDI) and coding professional, I’ve often heard the statement: If it’s not documented, it wasn’t done. I have used this statement educating physicians and nurses […]

Twenty-two months into this pandemic and we are starting to understand how all-encompassing COVID-19 is for the inpatient. Thus, when we realize that the inpatient medical record we are coding […]

Ever been caught off guard hearing about UFO sightings because the physics makes no sense? The Pentagon calls UFOs by a different name: UAPs (unidentified aerial phenomena). I was surprised […]

This is part one for a two-part series on FY 2022 ICD-10-CM/PCS updates. Look for part two in the next edition of JustCoding Inpatient. A popular morning radio show in […]

According to the Center for Disease Control’s National Diabetic Statistics Report 2020, there are 34 million people in the United States that have diabetes. That is 11 percent of the […]

I sat down with the 3M Health Information Systems Division President Garri Garrison to talk about connecting with clients and ensuring they are prepared for a smooth transition to automation […]

As Medicare Advantage (MA) organizations report chronic disease conditions using ICD-10-CM encounter data to the Centers for Medicare and Medicaid Services (CMS) for use in the hierarchical condition category (HCC) […]

Hierarchical Condition Categories (HCCs) have been used in the Centers for Medicare & Medicaid Services (CMS) risk adjustment payment model since 2004. That’s 17 years! More and more HIM professionals […]

In this next blog post in our blog series focused on the new E/M guidelines, I’m going to focus on Medical Decision Making (MDM), which along with Time, is a […]

I have encountered many physician practices and facilities in my role as coding analyst that are often stumped on the actual language needed to support specific ICD-10 codes for abdominal […]

The Official ICD Coding Guidelines state that a condition must be present at the time of the encounter, affect patient care or management and be clearly documented in order to […]