Coding Corner

COVID-19 updates

Some new COVID-19-related codes became effective Jan. 1, 2021.

Physician advisor as a career path

These physicians help ensure compliance with regulatory issues and advise on medical necessity and documentation needs.

Blood loss anemia

A key documentation issue is whether patients have lost enough blood to become anemic.

Hospitalist telehealth services

Medicare pays for three types of telehealth: telemedicine, virtual check-in, and e-visits.

Cytokine release syndrome

The sequencing of codes for cytokine release syndrome and causative conditions is complicated.


The coding of COVID-19 is a bit complicated, particularly when other manifestations are included.


Differing definitions of obesity categories can complicate documentation.

Liver failure

Combination codes often depend on the acuity and cause of liver failure.

Cerebrovascular disease

ICD-10-CM codes for cerebrovascular accident specify laterality and affected artery.

Peripherally inserted central catheters

Learn the codes for central venous access procedures.

DVT and PE

Documentation of deep venous thrombosis (DVT) and pulmonary embolism (PE) requires knowledge of certain criteria.


Avoid vague terms like unspecified or nonischemic cardiomyopathy in your documentation, and specify the cause whenever possible.

Point-of-care ultrasound—Part 2

Learn the codes for POCUS and see sidebar article for COVID-19 coding.

Point-of-care ultrasound—Part 1

Three documentation components are required for reimbursement of POCUS.

Multidrug resistance

The latest edition of ICD-10 includes new codes for antibiotic resistance.


The hallmark of schizophrenia is the presence of psychosis, or loss of contact with reality.


Depression should be classified by episode, severity, and state of remission.

Atrial fibrillation

Identify and document the four clinical types of atrial fibrillation.

Diabetic complications—Part 2

This month's column focuses on the chronic complications of diabetes.

Diabetic complications—Part 1

Learn to properly document common acute complications of diabetes.

Parkinson's disease

Accurate coding of Parkinson's disease requires documentation of the cause and any associated dementia.


Learn the diagnostic components of adult respiratory distress syndrome (ARDS).

HCCs explained

Hierarchical condition categories (HCCs) are used by Medicare for risk adjustment.

The ABCs of DRGs

Learn about the history and significance of diagnosis-related groups (DRGs).


Use recommended clinical terminology on every encounter to clearly describe patients' status: either HIV infection only or HIV disease.

Ask Dr. Pinson

Readers inquire about sepsis criteria, uncontrolled diabetes, and aspiration pneumonia.

Heart failure documentation and coding challenges

Identifying the systolic versus diastolic nature of heart failure is crucial for clinical management and coding purposes.

CMS tests easing E/M requirements

Current changes apply to outpatient visits, but they might be expanded to hospital medicine.

Fourth universal definition of myocardial infarction

The new definition replaces the term necrosis with the concept of myocardial injury.

New global definition for malnutrition

A new definition of malnutrition was published by the Global Leadership Initiative on Malnutrition in September.

Patient relationship category codes

Use of these code modifiers is voluntary for the time being but is expected to become mandatory in the near future.

Acute tubular necrosis

Review how to diagnose and document this common cause of acute kidney injury.

Chronic kidney disease, including transplants

The stage of chronic kidney disease is crucial to accurate documentation and can only be correctly assigned when glomerular filtration rate is at a stable baseline.


Whereas many major neurocognitive disorders may occur in younger people, the term dementia is customarily applied only to older adults.

Linking severe sepsis and hyperlactatemia

Is it acceptable, in coding for a patient with sepsis, to automatically link lactic acidosis to acute organ dysfunction?

Complications due to medications and toxic substances

ICD-10-CM classifies adverse therapeutic drug reactions as adverse effects, poisoning, or underdosing.

Opioid use disorders

ICD-10-CM contains a large, complex set of combination codes to describe opioid use and its many manifestations, consequences, and related conditions.

Alcohol use disorders

Alcohol-induced conditions are complications directly due to alcohol use disorder, but because most can also occur independently, clinicians must specifically document the connection.

Alcohol use disorders

Learn the ICD-10-CM terminology and instructions and DSM-5 definitions needed to document alcohol use disorder.

Advance care planning

Medicare began paying for advance care planning services in 2016 to encourage such conversations and compensate clinicians for the time spent having them.

ICD-10 embraces definitions of MI

Learn the new codes and coding rules for the six types of MI that were recently recognized by the International Classification of Diseases, 10th Revision.

ICD-10 embraces definitions of MI

Learn the definitions of and distinctions among the six types of myocardial infarction (MI) that were recently recognized by the International Classification of Diseases, 10th Revision.

Acute pancreatitis

Clinicians should apply the American College of Gastroenterology's diagnostic criteria for accurate documentation and billing.

Ask Dr. Pinson

This month's column features questions from readers.

Postprocedural respiratory failure

How to properly make and document the diagnosis of respiratory failure following surgery.

More on COPD documentation and coding challenges

Additional advice offered on accurately coding the severity of chronic obstructive pulmonary disease.

Documentation and coding challenges with COPD

Learn more about one of the most frequent reasons for inpatient admission.

Surviving Sepsis Campaign adopts Sepsis-3 definition

If physicians do not follow severe sepsis management measure definitions, a deficiency in the quality of care for severe sepsis management could be reported to the CDC and CMS.

Surviving Sepsis Campaign adopts Sepsis-3 definition

If physicians do not follow severe sepsis management measure definitions, a deficiency in the quality of care for severe sepsis management could be reported to the CDC and CMS.

Altered mental status

The encephalopathic and intracranial disease processes causing acute alteration in mental status is discussed in the second of two columns on the topic.

Altered mental status

Altered mental status due to psychiatric causes is discussed in the first of two columns on the topic.

Malnutrition revisited

Criteria remain problematic from the clinical, coding, and regulatory perspectives and deserve more attention and discussion

What is clinical validation?

Diagnoses documented in a patient's record must be substantiated by clinical criteria generally accepted by the medical community.

More crucial coding rules for clinicians

Such topics as the uncertainty rule, signs and symptoms, abnormal findings, and more are covered.

Crucial coding rules for clinicians

Principal diagnosis, secondary diagnoses, principal procedure, and present on admission are covered.

Connecting the causes and codes for pneumonia

The rules that govern code assignment for pneumonia bear little relationship to long-accepted clinical documentation practices.

Take notice of the NOTICE act

Medicare beneficiaries who receive observation services as an outpatient for more than 24 hours are now required to be given formal notice of observation requirements and attendant financial obligations.

New CMS specialty code and more on Sepsis-3

This column discusses the new CMS specialty code for hospital medicine and developments in sepsis criteria.

Medicare reports on the 2016 Physician Fee Schedule Value Modifier

For physicians who haven't begun working on the Value Modifier, 2016 is the year for immediate action.

Split/shared services

To constitute a substantive portion of an E/M visit, all or some of the key components should be provided: history, physical exam, and/or medical decision making.

Sepsis-3: The world turned upside down

New definitions of sepsis and septic shock represent a radical departure from previous criteria.

Sepsis is still confusing

Diagnostic criteria are often misapplied.

Blood loss anemia

Making a distinction between acute and chronic blood loss anemia is important.

Stroke and TIA

A transient neurologic deficit lasting 24 hours or more, even when imaging studies are unremarkable, is a cerebrovascular accident, not TIA.

ICD-10: A few more new documentation needs

Coma, hepatic encephalopathy, pancreatitis, diabetes, and hypertension are discussed.

ICD-10: New documentation opportunities

Depression, sepsis, respiratory failure, stroke, and heart disease are discussed.

ICD-10: Contingency plan created

CMS has established a communications and coordination center as well as other measures to ease the transition.

ICD-10-CM specificity: The sky isn't falling

ICD-10-CM documentation requirements will not require much more from physicians than is already needed

ICD-10-CM specificity: The sky isn't falling

ICD-10-CM allows much greater specificity of diagnosis codes, it will require little more from physicians than ICD-9

Pulmonary hypertension and pulmonary heart disease

Documentation and coding for these cases are surprisingly challenging.

Medicare's 2-midnight rule

The 2-midnight rule and inpatient certification are 2 separate but related issues, with the former being the benchmark for meeting the length of stay required for inpatient certification


Clinicians often struggle with the distinction between delirium and encephalopathy.

Coding for intellectual, developmental disabilities

Documentation of severity and/or the associated IQ is required for correct coding and severity-of-illness assignment.

What is a clinical documentation improvement program?

Programs aim to incorporate the terminology needed to accurately translate a patient's condition into precise codes.

Documentation for psychiatric disorders

Coding visits for patients with depression, bipolar disorder, and schizophrenia.

How documentation impacts VBPM, PQRS

Starting in 2015, what hospitalists record will affect their facilities' Value-Based Payment Modifier and Physician Quality Reporting System results.

HCAP: What's the organism?

Correct coding requires documentation of the presumed or confirmed causative organism.

Uncertainty is the essence of medicine

Learn the best terminology for documenting uncertain diagnoses.

Heart failure: a coding classification quandary

Pathophysiologic classification and acuity are important in documentation of heart failure.

ICD-10 will bring new documentation opportunities

Although the transition to ICD-10 has been delayed, hospitalists should become familiar with the new code set in advance.

Diagnostic documentation for oncology patients

Two common and serious conditions are associated with malignancy and cancer treatment: pancytopenia and sepsis/systemic inflammatory response syndrome.

Diagnostic documentation for oncology

Specific documentation is needed to reflect the severity of illness of these patients, as well as their associated risks, complexity of care, resources, and costs of care.

HIV-positive status and AIDS

An AIDS-defining condition takes precedence over CD4+ counts in making the diagnosis.

Acute coronary syndrome: A cardiac conundrum

Physicians should view the label as provisional and evaluate further for a more specific diagnosis.

Physical exam of 1995 or 1997?

For any patient encounter, either may be used but not a combination of the two.

Revisiting respiratory failure

An acute exacerbation of chronic respiratory failure represents acute-on-chronic respiratory failure, and acute hypoxemic criteria must be applied with caution in these patients.

Revisiting respiratory failure

Patients with congestive heart failure, pneumonia and chronic obstructive pulmonary disease are particularly susceptible.

A new approach to inpatient admission status

Physicians must consider certain Medicare regulations, requirements when deciding whether to admit.

A new approach to inpatient admission status

Physicians, not the hospital or case managers, are responsible for making the correct determination.

Hospital value-based purchasing

Physician documentation can affect a hospital's value-based purchasing score—and thus, its bottom line.

Code carefully with nutrition guidelines

This column discusses classic chronic malnutrition and how it differs from acute nutritional deficiency.

Medical decision making for E/M services

This column focuses on the risk of complications, morbidity and/or mortality.

Documenting pain

Other than a patient abusing or illegally diverting medications, there are no excuses for failing to provide appropriate medications that will mitigate suffering.

Medical decision making for E/M services

This month's column focuses on quantifying amount and complexity of data.

Medical decision making for E/M services

This month's column focuses on determining the number of diagnoses or management options when documenting complexity of medical decision making.

Documentation of medical necessity

Acute chest pain, acute coronary syndrome, acute myocardial infarction and bronchospastic conditions are discussed.

Documentation of medical necessity

Congestive heart failure, syncope and presyncope, and transient ischemic attack are discussed.

Documentation of medical necessity

“Medical necessity” is a vague standard, but it's a crucial one to try to understand.

Counseling and coordination of care

In certain situations, counseling and coordination of care can help determine which code to assign.

2012 diagnostic documentation update

If there is any certainty in the health care industry today, it is that things will change.

Critical care

Critical care requires constant attendance and supervision by the physician providing direct management of acute, complex, potentially life-threatening situations.

Hospitalist physical exam for E&M

An intuitive, clinical approach can simplify the task of providing optimal documentation of physical examination.

Problems with pulmonary edema

Acute pulmonary edema is a serious condition, but coding rules don't always give it its due.

Functional quadriplegia

Functional quadriplegia is clinically comparable to physical quadriplegia but is rarely diagnosed.

Observation status: making the right call

Understanding when to admit a patient to observation status or to inpatient status can be confusing and challenging—and so can knowing when it's appropriate to bill for one or the other.

How hospitalists handle the history

The medical history is one of the three key components of every patient encounter.

Bleeding and acute blood loss anemia

In coding, anemia is a separate identifiable condition that contributes independently to patient risk and severity of illness.

Getting ready for ICD-10 changes

Oct. 1, 2013, is the current deadline for switching from ICD-9.

Evaluating and managing hospital E/M services

Key components of E/M must be documented for every encounter

Whose documentation counts?

Understanding whose documentation can actually be used for inpatient coding purposes is often a source of confusion and controversy.

Prolonged service proficiency

The coding and billing of prolonged services depend on the face-to-face time spent with the patient over and above the average.

Correct classification of chronic kidney disease

As the U.S. population ages, chronic kidney disease is becoming more and more prevalent.

Placing priority on pressure ulcers

Current emphasis on public reporting of quality scores has helped make accurate documentation and effective management of pressure ulcers crucial health care considerations.

Recognizing acute respiratory failure

Acute respiratory failure is a common diagnosis, especially among patients admitted with heart failure, pneumonia or chronic obstructive pulmonary disease.

New subsequent observation codes

Three new CPT codes have been developed to address longer-stay observation care.


The clinical distinction between community-acquired pneumonia and health care-associated pneumonia is crucial for correct management and antibiotic selection.

Weighing in on BMI

A patient's body mass index can have a profound effect on the complexity of care and the risks of complications, morbidity and mortality.

Chronic respiratory failure

Chronic respiratory failure is usually recognized by a combination of chronic hypoxemia, hypercapnia and compensatory metabolic alkalosis.

Urinary catheter-associated infections: Before or after admission?

Any infection related to a device or catheter of any type is classified for coding purposes as a complication of care.

Sepsis: SIRS due to an infection

The current definition of sepsis is not well known by most physicians. Many think a diagnosis requires positive blood cultures and is associated with an extremely grim prognosis, but this is no longer so.

Drug dependence and abuse

For coding purposes, the term "addiction" is not used, but is treated as synonymous with "dependence."

Acute renal failure

Documentation and coding of acute renal failure can be problematic, as many different criteria may be used to define the condition.

Accelerated hypertension

Coding terminology hasn't caught up with the currently accepted clinical diagnostic terms for severe, uncontrolled hypertension.


Most patients who are admitted to the hospital with the symptom of mental status alteration actually have encephalopathy as the cause.

Heart failure: The importance of precision

For coding purposes, it is no longer enough to say that patients have "CHF" or "congestive heart failure."

Documenting altered mental status

When a patient is admitted with an acute change in mental status, the physician should drill down to determine the known or suspected causes of the change.

Respiratory failure in COPD patients

In some cases of chronic obstructive pulmonary disease, it may be appropriate to assign a principal or secondary diagnosis of acute respiratory failure.

Documenting and billing for critical care services

To avoid rejection of critical care codes, physicians must be familiar with coding definitions, and documentation must reflect the professional services that support the codes.

Consultation confusion

CMS stopped paying for services billed as consultations as of Jan. 1, 2010. What does this mean for hospitalists?

Documenting adverse drug reactions and poisonings

Adverse effects of a correctly administered drug or drugs must be coded and reported differently than the misuse of a drug, which is classified as "poisoning" in ICD-9-CM coding.

Walking the tightrope of medical necessity

Our columnist discusses key elements of deciding the appropriate level of care for a given patient (inpatient versus outpatient or outpatient with observation).

Using observation services

Hospitals often struggle to achieve compliance with CMS regulations for determining whether a patient should be classified as an inpatient or an outpatient with observation services.

CMS updates payments, quality measures for 2010

October 1 is an important time to evaluate coding changes because it's when CMS' annual update to the inpatient prospective payment system (MS-DRGs) takes effect.

Accurate coding for transfer to post-discharge facilities

Accurate ICD-9-CM codes for diagnoses and procedures performed during a hospital stay will only partially determine payment. Discharge status codes must be given equal attention.

Reporting malnutrition

Documenting malnutrition as a secondary diagnosis helps establish the severity of an underlying illness, improves publicly reported data, and can increase reimbursement to the hospital.

Coding cardiac conditions: Beyond acute coronary syndrome

Acute coronary syndrome is a very popular diagnosis frequently documented when a patient presents to the hospital with chest pain thought to be cardiac in origin. For accurate coding, physicians should document unstable angina or acute myocardial infarction.

Reporting diabetic manifestations

Diabetes mellitus is on the rise and data regarding its type, manifestations and impact on cost and length of stay are needed to assess the effectiveness of current evaluation and management.

Documenting skin ulcers: The pressure is on

Physicians must carefully identify patients at high risk of developing pressure ulcers and then initiate and document prevention strategies.

Coding Corner

Distinguishing between stroke and TIA requires taking into consideration various definitions, including cerebral infarction, cerebral hemorrhage, aborted stroke, impending stroke and TIA.

Insufficient insufficiency

Physicians often use the term renal insufficiency to communicate the status of a patient's renal function, but this isn't enough when the medical record supports a more specific condition.

Is it sepsis?

John Doe was brought to the emergency department by ambulance from a local nursing home.

Billing and coding

Specific documentation helps optimize payments for heart failure

Coding corner

Billing for interactions with a patient's family or other caregiver More than 44 million Americans care for an adult family member or friend. Physicians often will discuss the care of a patient with the patient's caregivers, and may be able to bill for these interactions.

Coding corner

Coding corner: ICD-9 changes take effect

Coding corner

Billing in the ED and transitional care units

Coding corner

Coding corner Billing for routine perioperative care by hospitalists may require modifiers

Coding corner

Advice on discharge billing, and whether critical care codes depend on location

Coding Corner

Billing Medicare based on time and revised rules on verbal orders