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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...
The classifi...
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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What is the appropriate diagnosis code assignment for anti-neutrophil cytoplasmic autoantibody (ANCA) vasculitis with nephritic syndrome?
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A patient presents to the hospital for treatment of an exacerbation of cystic fibrosis (CF) and bronchiectasis. Our physicians state that bronchiectasis is common in CF, and that the admission is f...
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A patient presents with a sacral deep tissue injury (DTI), and undergoes surgical debridement. Following excisional debridement, the provider documents “Stage 4 pressure ulcer of the sacrum.” S...
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