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A patient stopped taking his prescribed dose of Amlodipine after running out of the antihypertensive medication several days ago. The provider documented that the patient’s blood pressure was sta...
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My facility has interpreted new HIV coding guideline I.C.1.a.2.i “History of HIV managed by medication” to mean that code B20, HIV disease, should be reported for any HIV positive patient on an...
The intent o...
An obstetrical patient is admitted to labor and delivery for a planned cesarean section due to breech presentation. The provider documents the gestational weeks as "40 weeks and 2 days." Is it appr...
Yes. When pr...
An obstetrical patient is admitted to labor and delivery for a planned cesarean section due to breech presentation. The provider documents the gestational weeks as “40 weeks and 2 days.” Is it ...
Yes. When pr...
Please clarify “completed weeks of gestation” when assigning codes: O48.0, Post-term pregnancy, O48.1, Prolonged pregnancy, O75.82, Onset (spontaneous) of labor after 37 completed weeks of gest...
In ICD-10-CM...
A 24-year-old patient was admitted with shortness of breath and fever due to postpartum sepsis and postpartum urinary tract infection (UTI). The patient had a history of spontaneous vaginal deliver...
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What is the appropriate ICD-10-CM code(s) for a diagnosis of unspecified hyperlipidemia and hypercholesterolemia?
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What is the appropriate ICD-10-CM code(s) for a diagnosis of mixed hyperlipidemia with hypercholesterolemia?
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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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