Medical coding

Introduction In inpatient coding, accurate identification and reporting of diagnoses directly affect reimbursement, quality reporting, and hospital performance metrics. One of the most important concepts for coders to understand is the role of Complications or Comorbidities (CCs) and Major Complications or Comorbidities (MCCs) within the Medicare Severity Diagnosis-Related Group (MS-DRG)…

Imaging services play a major role in modern healthcare by helping physicians diagnose conditions, monitor treatment progress, and guide procedures without invasive surgery. For medical coders, assigning accurate ICD-10-PCS codes for imaging procedures requires a strong understanding of the Imaging section structure and its character definitions. In ICD-10-PCS, imaging procedures are reported…

Opportunistic infections are serious infections that usually occur in patients with weakened immune systems. These infections are common in individuals with conditions such as HIV/AIDS, cancer, autoimmune diseases, organ transplants, or patients receiving chemotherapy or immunosuppressive therapy. From a medical coding perspective, opportunistic infection coding can be challenging because…

Wound care coding is one of the most challenging areas in medical coding and revenue cycle management. These claims often involve complex medical histories, multiple diagnoses, debridement procedures, skin substitutes, and detailed documentation requirements. Even a small documentation gap can lead to claim denials, payer audits, or reimbursement delays. With CMS increasing scrutiny on wound care…

The American Medical Association (AMA) has announced major updates to maternity care CPT codes for the 2027 CPT code set. These changes are designed to improve coding accuracy and allow maternity services to be reported more specifically across every stage of pregnancy. The updates include: 17 deleted CPT codes 12 new CPT codes 6 revised CPT codes New coding guidelines and subsections Although…

The Centers for Medicare & Medicaid Services (CMS) released the 2027 Hospital Inpatient Prospective Payment System (IPPS) Proposed Rule on April 14, 2026, introducing several important ICD-10-CM and ICD-10-PCS coding updates. Compared to recent years, the number of proposed changes is smaller, but many updates focus on improving clinical specificity, supporting more accurate documentation, and…

Artificial openings, also known as stomas, are surgically created openings that connect an internal organ to the outside of the body. These openings may be temporary or permanent and are commonly created to: Eliminate waste Provide nutrition Maintain an airway Examples include: Tracheostomies Gastrostomies Colostomies Ileostomies Urinary stomas For medical coders, accurate coding of…

The Centers for Medicare & Medicaid Services (CMS) introduced six new HCPCS Level II codes in the April 2026 Integrated Outpatient Code Editor (I/OCE) Version 27.1. These updates are effective January 1, 2026 and focus on procedures involving hypoglossal nerve neurostimulators used to treat obstructive sleep apnea (OSA). For medical coders, understanding these new codes is essential to ensure…

As of October 1, 2025, ICD-10-CM introduced a new code—E11.A (Type 2 diabetes mellitus in remission)—bringing a major shift in how coders capture improved patient outcomes. This update recognizes that type 2 diabetes can go into remission, and it allows providers and coders to accurately reflect that success in medical records. What is Code E11.A? E11.A is used for patients who: Have a history…

Accurate coding of alcohol- and drug-related disorders in ICD-10-CM requires more than just identifying the substance involved. Coders must carefully interpret provider documentation, clinical terminology, and coding hierarchy to assign the most appropriate code. This guide simplifies F10–F19 coding rules, severity hierarchy, remission guidelines, and documentation tips to help medical coders…

Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of morbidity and mortality worldwide, affecting nearly 10% of adults over age 40. For medical coders, one of the most challenging scenarios is accurately coding COPD with acute exacerbation (AECOPD)—especially when it progresses to respiratory failure. This guide breaks down ICD-10-CM coding rules, sequencing guidelines, and clinical…

Heart failure coding in ICD-10-CM can be complex—especially when documentation includes terms like reduced ejection fraction, preserved EF, or mid-range EF. For medical coders, understanding how clinical classification aligns with coding guidelines is essential for accurate reporting and reimbursement. This guide simplifies left-sided heart failure classification, ICD-10-CM coding rules, and…

Understanding when to code a procedure as a biopsy versus an excision or other treatment is essential for accurate CPT coding, compliance, and reimbursement. Misinterpreting the intent of the procedure is one of the most common coding errors. This guide simplifies biopsy coding rules and helps you confidently distinguish between diagnostic sampling and definitive treatment procedures. Biopsy vs…

Accurate fracture coding in ICD-10-CM is critical for proper reimbursement, compliance, and clinical documentation. One of the most important—and often misunderstood—components is the 7th character, which communicates both the type of fracture and the stage of care or healing. This guide breaks down everything medical coders need to know to confidently assign the correct 7th character for…

Over the past decade, the ICD-10-PCS code set has consistently required seven characters to accurately report inpatient procedures. Each character represents a distinct component of the procedure performed. Within the Medical and Surgical section, the sixth character identifies the device used during the procedure. Definition of a Device (Character 6) The sixth character is used to report any…

Staying updated with CPT® code changes is critical for every medical coder, biller, and healthcare organization. The American Medical Association (AMA) has released mid-year CPT® updates for 2026, impacting Category I, Category III, and Proprietary Laboratory Analyses (PLA) codes. Although these updates are part of the 2027 CPT® code set, they become effective July 1, 2026, making early…

Accurate reporting of assistant-at-surgery services requires a structured approach to ensure compliance, appropriate reimbursement, and audit readiness. Coders should consistently follow three essential steps when an assistant participates in a surgical procedure: Step 1: Verify Procedure Eligibility Confirm that the procedure allows reporting of an assistant-at-surgery service by reviewing the…