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A patient with a known history of pulmonary hypertension, chronic obstructive pulmonary disease and cor pulmonale presents with new-onset shortness of breath, increasing peripheral edema and severe...
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A patient with anemia and thrombocytopenia is admitted with fever and neutropenia. The provider documented that the neutropenia and anemia are secondary to chemotherapy for medulloblastoma with spi...
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ICD-10-CM provides two codes for capturing gestational age of 42 weeks or more: Z3A.42, 42 weeks of gestation of pregnancy, and Z3A.49, Greater than 42 weeks of gestation of pregnancy. Clarificatio...
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During a routine physical examination of the newborn, the provider noted a possible systolic ejection murmur, and recommended further workup post discharge. In ICD-10-CM, under the terms murmur, sy...
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A patient who was diagnosed with spinal stenosis underwent L2-L3 posterolateral fusion, and repair of midline durotomy. In the body of the report, the provider documented that the durotomy was prob...
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We have noticed discrepancies in the documentation of gestational age for newborns. The obstetrician will document the gestational age in the mother’s record and the pediatrician will document a ...
For the newb...
Term birth is marked on the Newborn Physical Examination sheet. The number of weeks from the mother’s chart (which is put in the baby’s chart) is 41 4/7. The mother’s chart is coded with the ...
No, it would...
The Official ICD-10-CM Guidelines for Coding and Reporting in the chapter on the perinatal period state, “For coding and reporting purposes the perinatal period is defined as before birt...
Yes, the per...
Do two conditions have to be listed together in the diagnostic statement in order to assume an association?
...It is not re...
We are considering developing internal coding guidelines and obtaining medical staff approval to code acute blood loss anemia. The guidelines would specify lab values pre- and post-surgery, as well...
No, it is no...