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A 28-year-old female status post pump and catheter exchange of her intrathecal baclofen system developed localized swelling in the lumbar wound. The surgeon noted, “No visible leak but orifice ar...
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A patient presents for treatment of a normal pressure hydrocephalus. The provider notes in the past medical history, “History of lymphoma, status post radiation and chemotherapy in remission.” ...
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A patient presents for preoperative medical evaluation, and the provider notes, in the past medical history, “History of non-Hodgkin lymphoma in remission with no evidence of d...
The encephal...
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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