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A patient who is status post colectomy presents with chills, abdominal pain, and fever. On examination, he was found to have feculent wound drainage and was diagnosed with anastomotic dehiscence of...
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A patient presented with palpitations and presyncopal symptoms, which he experienced while going from a sitting to standing position. The provider diagnosed sinus bradycardia and multiple premature...
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The patient became unresponsive after receiving intravenous Dilaudid. The provider documented “Unresponsiveness due to Dilaudid.” How is this diagnosis coded?
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A 15-year-old male presented with a growing mass on the right side of his head. After diagnostic workup, the provider documented “Craniofacial deformity secondary to leptomeningeal cyst/growing s...
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When the provider documents “sepsis due to aspiration pneumonia,” is a code for the sepsis, or the aspiration pneumonia assigned as the principal diagnosis?
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A patient was discharged with the following diagnoses: 1. sepsis secondary to aspiration pneumonia, 2. aspiration pneumonia secondary to probable gram-negative bacteria. Both diagnoses were present...
When sepsis ...
An 84-year-old male with chronic gait instability is admitted after a fall. The provider’s documentation states that the patient’s gait instability is related to chronic cerebrovascular acciden...
Although the...
A patient, who had suffered a traumatic brain injury (TBI) without loss of consciousness secondary to a high-speed motor vehicle accident, developed brain herniation. There is an Excludes1 note tha...
If the physi...
We have been advised by an outside source that we are to assign code B20, Human immunodeficiency virus [HIV] disease, for every patient who is HIV positive and is treated for any condition that is ...
Provider doc...
Current literature states that cryptococcal meningitis is a major HIV-related infection. When a patient who is HIV positive presents due to this condition, is it appropriate to assume a linkage bet...
The ICD-10-C...