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A patient is diagnosed with hyperlipidemia associated with type 2 diabetes mellitus. Is hyperlipidemia considered a specified type of diabetic manifestation? What is the correct code assignment?
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A patient presented for a 6-month follow-up visit for type 2 diabetes and hypertension. The patient’s diabetes was documented as being well-controlled. Provider documentation also indicated “mi...
Diabetic mic...
A 39-year-old patient was admitted at 38 weeks and 5 days gestation with spontaneous rupture of membranes (SROM). Pitocin augmentation was administered, and the patient progressed to complete cervi...
SROM occurri...
Many patients present with depression and dementia without documentation of a relationship by the provider. We understand the presumed linkages in the classification with the subterm “with,” ho...
The classifi...
A patient seen in the outpatient setting was noted to have dementia, anxiety, and depression. Assuming that these conditions meet reporting requirements, are they coded as related based on the “w...
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A patient had a final diagnosis of moderate dementia with disturbance of behavior and psychotic disorder with hallucinations. Is it appropriate to link dementia to disturbance of behavior and psych...
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What is the correct diagnosis code assignment for an encounter for the administration of prophylactic long-acting monoclonal antibodies, such as Nirsevimab-alip (Beyfortus™), for respiratory sync...
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A 7-year-old patient with a past medical history of asthma was admitted for acute hypoxic respiratory failure and moderate persistent status asthmaticus due to secondary exposure to vaping. Is it a...
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Our facility is seeing an increase in documented use of vaping substances other than nicotine. How should vaping be reported when the substances are listed as flavorings, cannabidiol (CBD), tetrahy...
The reportin...
Our providers have been documenting “vaping,” “daily vaping,” or “vaping use” of marijuana without further specification. How is “vaping” of marijuana reported when documented? Woul...
Documentatio...