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Our facility is seeing documentation with terms such as “degenerative scoliosis” or “scoliosis secondary to degeneration” or other similar documentation that links scoliosis to an underlyin...
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A patient with a history of seizure-like episodes on multiple non-epileptic medications presented for encephalographic (EEG) monitoring. The EEG did not demonstrate epileptic seizures. The provider...
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The patient, who is status post bilateral total hip replacement, presented with a fluid collection around the right hip. Infection was ruled-out, but high levels of metal ions were found. As a resu...
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A 61-year-old male with acute monocytic leukemia was admitted with fatigue, fever, chills, night sweats, leg pain, weight loss and shortness of breath. CT scan demonstrated signs of descending and ...
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The patient, who had a recent history of stroke on antiplatelet therapy and a history of outpatient radiotherapy for prostate cancer, is admitted with active rectal bleeding associated with radiati...
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A patient with a clogged gastrojejunostomy (GJ) tube is admitted to undergo gastrojejunostomy tube change. What is the appropriate ICD-10-CM diagnosis code assignment for the GJ tube change?
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The patient is a 72-year-old woman diagnosed with lumbar stenosis and spondylolisthesis with scoliosis. She underwent decompressive laminectomy at L2, L3, and L4. This was followed by lumbar spinal...
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A woman is diagnosed with a pseudoangiomatous stromal hyperplasia of the breast (PASH). How is this condition coded in ICD-10-CM?
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A patient underwent a colonoscopy because of a positive Cologuard® test. The colonoscopy demonstrated no abnormal findings. What is the appropriate diagnosis code for this encounter?
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A patient is referred for a colonoscopy due to the positive results of a Cologuard® test. During colonoscopy, a cecal polyp was found and removed. The preoperative diagnosis is screening colonosco...
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