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An infant born at 39 weeks gestation was noted to have Mongolian spots on the skin of the buttocks and lumbar spine. Findings of Mongolian spots were also listed in the discharge summary. Should Mo...
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A patient developed a postoperative epidural hematoma following an L3-L4 and L4-L5 laminectomy, medial facetectomy, and foraminotomy. Code G97.62, Postprocedural hematoma of a nervous system organ ...
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A 32-year-old patient with a history of gender dysphoria was admitted for radial forearm phalloplasty. Following the radial forearm flap phalloplasty, the flap was assessed intraoperatively with a ...
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A patient presents with spontaneous intracranial hypotension due to a cerebrospinal fluid (CSF) fistula at the right T8-T9 level. The symptoms are positional headaches, weakness of the left arm and...
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A patient who is 22 weeks gestation was admitted for a planned induction of labor via buccal administration of an abortifacient for termination of pregnancy due to a lethal fetal anomaly, holoprose...
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An obstetric patient presents at 38 weeks and four days gestation for a scheduled primary cesarean section due to fetal malpresentation and fetal growth restriction (FGR). Currently, in ICD-10-CM, ...
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A 55-year-old patient presents for a biannual physical exam and review of chronic medical conditions. Upon examination, the patient reports chronic pain of the left lower and upper extremities. Pro...
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A patient presents for a routine cardiovascular examination. The provider documents, “Diabetes without complications.” This patient also has stage 3 chronic kidney disease (CKD). When the provi...
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A patient presented for an annual wellness visit. The provider documented, “Diabetes mellitus without complications.” This patient also has dermatitis. When the provider documents DM without co...
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A patient with positive blood cultures for Candida glabrata was diagnosed with candida fungemia and treated with intravenous antifungals. There is not a specific index entry to capture this conditi...
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