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A patient, with type 2 diabetes mellitus, presented for follow up of a previous traumatic laceration, which the patient reported had worsened. The provider documented diabetic ulceration secondary ...
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A 24-year-old pregnant patient was admitted for induction of labor. Her medical history includes subclinical hypothyroidism, which is being treated with levothyroxine. When referencing “hypothyro...
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A patient with guaiac positive stool presents for outpatient esophagogastroduodenoscopy (EGD) and colonoscopy. The EGD revealed a non-bleeding gastric antral erosion. The colonoscopy revealed a pol...
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An obstetric patient presents due to “contractions” at 37 weeks gestation. During the encounter, the provider noted “No vaginal bleeding or rupture of membranes.” The patient was released, ...
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When the provider’s documentation indicates a patient has both depression and anxiety by using terminology such as depression and anxiety or depression with anxiety, are these diagnoses coded sep...
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In the outpatient setting, the provider documented gastrointestinal (GI) bleeding likely due to gastric ulcer and diverticulosis. Although the provider confirmed the gastric ulcer and diverticulosi...
In the outpa...
A patient diagnosed with asthma is currently on prescribed inhaled albuterol, “as needed” for control of symptoms. Since the medication is prescribed for long-term treatment of asthma, would it...
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A 70-year-old patient with a history of nonalcoholic steatohepatitis (NASH) cirrhosis complicated by hepatic encephalopathy and diabetes presented to the emergency department (ED) secondary to alte...
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A 71-year-old patient with multiple vessel coronary artery disease and severe aortic valve stenosis underwent coronary artery bypass graft (CABG) surgery and aortic valve replacement (AVR). Followi...
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A patient undergoes surveillance upper gastrointestinal (GI) endoscopy due to a personal and family history of familial adenomatous polyposis (FAP). The endoscope is introduced into the mouth and a...
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