Burn Medical Specialty: General Medicine Description: First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury. CHIEF COMPLAINT: Burn, right arm. HISTORY OF PRESENT ILLNESS: This is a Workers' Compensation...
What to Do With Old, Outdated Medical Coding Manuals Medical coding manuals are essential tools—but they don’t stay current forever. Each year, CPT, ICD-10-CM, and HCPCS Level II code sets are updated with new codes, deleted codes, and revised guidelines. Using...
Stages, Guidelines & Coding Tips (ICD-10-CM) Pressure ulcers (also called pressure injuries or decubitus ulcers) are a high-risk, high-scrutiny diagnosis in medical coding. They impact quality reporting, reimbursement, HCC risk adjustment, and hospital-acquired...
What Is Multiple Sclerosis (MS)? Multiple sclerosis (MS) is a chronic, immune-mediated disease of the central nervous system (CNS), which includes the brain, optic nerves, and spinal cord. In MS, the immune system mistakenly attacks myelin, the protective insulation...
Angina - Consult Medical Specialty: Emergency Room Reports HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old woman whom I have been following, who has had angina. In any case, today, she called me because she had a recurrent left arm pain after her stent,...
Urology Medical Coding: Complete Guide with New Codes, Guidelines, and Tips What Makes Urology Coding Unique Urology coding must capture a wide range of services — from office visits and diagnostic testing to endoscopic procedures and complex prostate or...
How to Make an Inexpensive Medical Coding Book Carousel with a Swivel Base for Open Manuals Medical coding requires constant cross-referencing between large, heavy books like the CPT and ICD-10-CM manuals. Laying them flat across your desk wastes space, strains your...
It Didn’t Start With ChatGPT — and It Won’t Replace Coders Artificial Intelligence (AI) has suddenly become a hot topic in healthcare and medical coding, largely due to highly visible tools like ChatGPT, Copilot, and Gemini. This has led to understandable concern...
Medical Specialty: Orthopedic Description: Anterior cervical discectomy and removal of herniated disk and osteophytes, and decompression of the spinal cord and bilateral nerve root decompression. Harvesting of autologous bone from the vertebral bodies. Grafting of...
2026 Quality Payment Program (QPP) and MIPS Updates: What Medical Coders Need to Know The Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act (MACRA) continues to evolve for the 2026 performance year. CMS released the Calendar Year...