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An 84-year-old patient was admitted to our long-term care hospital (LTCH) for posttraumatic subarachnoid hemorrhage and subdural hematoma. She was treated medically at an acute care facility and wa...
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Surgical treatment is provided in the Official Coding Guidelines as an example of active treatment for the selection of the 7th character for initial encounter for codes in Chapter 19. If a patient...
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The patient presents for surgical treatment of a malunion of a fracture of the humeral greater tuberosity. This is the first time the malunion is being surgically treated, and the patient did not d...
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The patient had previously undergone open reduction internal fixation of a fracture. Three days post-discharge the patient is readmitted due to pain at the fracture site. An x-ray noted improper al...
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When a Rh negative mother delivers at term without complication, and she is administered Rhogam prophylactically during the admission, would code Z31.82, Encounter for Rh incompatibility status, be...
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A 12-year-old patient presents to the emergency department (ED) after a car accident. She was a passenger in a car that was hit from the side by a sport utility vehicle (SUV), and the patient susta...
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The above patient returns three days later for a wound check with the pediatrician. The pediatrician only inspected the wounds. The wounds were found to be healing nicely, and no other intervention...
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The same patient now presents to the pediatrician’s office for suture removal. The pediatrician checks the wounds and removes sutures from both the scalp and cheek. Should code Z48.02, Encounter ...
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A three-year-old male presents to the Emergency Department (ED) with a painful right forearm and limited use of his arm. The injury occurred when the patient and his older brother were roughhousing...
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