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The provider’s final diagnostic statement lists, “Pressure injury to mucosal membrane of penis from Foley catheter.” There are no ICD-10-CM codes for mucosal membrane pressure injuries and th...
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A patient was admitted for treatment of acute respiratory distress syndrome due to COVID-19. The patient was intubated on day 2 of the admission; later in the stay, the provider identified a mucosa...
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A morbidly obese patient was admitted to the hospital with a deep tissue pressure injury (DTPI) to the bilateral gluteal region, which was revealed during the admission to be a stage IV pressure ul...
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A patient presented for follow-up of multiple medical conditions. The provider documented Class 3 obesity as one of the patient’s medical conditions. Would it be appropriate to assign code E66.01...
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What is the appropriate ICD-10-CM code assignment for metabolic bone disease (MBD) when the condition meets requirements for coding as an additional/secondary diagnosis?
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A patient was admitted to the intensive care unit for monitoring of hyponatremia. Following treatment with intravenous fluids the sodium level normalized, however, the patient developed urinary inc...
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A patient was admitted with delirium and hallucinations secondary to serotonin syndrome. The provider was queried and clarified that the serotonin syndrome was due to the adverse effect of prescrib...
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A 97-year-old female patient with an ataxic gait, presented for management of multiple medical conditions. The provider documented vestibular ataxia and prescribed Meclizine to treat gait instabili...
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The patient had a chest computerized tomography angiography (CTA) which revealed pulmonary emboli in the segmental branches of the right middle and lower lobes of the lung. The radiologist also not...
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A patient with gastroesophageal reflux disease underwent an outpatient manometry study. The provider’s impression states, “Manometric evidence of a hiatal hernia with esophagogastric junction o...
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