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A patient with a history of constipation presented for high resolution anorectal manometry. The provider diagnosed pelvic floor dyssynergia. In ICD-10-CM, there is no Alphabetic Index entry for thi...
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A patient is admitted with a liver mass and the provider’s final diagnostic statement lists, “Liver mass possibly hepatic cholangiocarcinoma, pending pathology.” How is this diagnostic statem...
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During an outpatient encounter, a 66-year-old male underwent an invasive cardiopulmonary exercise test (iCPET). The test summary states, “Evidence of cardiovascular limitation due to preload insu...
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A patient developed hypoxia due to acute pulmonary edema following a near drowning in the pool at his home. The patient was treated with supplemental oxygen and noninvasive ventilation (NIV). How i...
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A patient with a dichorionic diamniotic twin pregnancy was admitted for a scheduled primary cesarean section. She was also diagnosed with intrahepatic cholestasis of pregnancy. Code O26.62, Liver a...
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A patient with bilateral traumatic above knee amputations underwent placement of a Stage 1 Osseointegrated Prostheses for the Rehabilitation of Amputees (OPRA) device. Following incision, an osteot...
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The same patient presented for Stage 2 OPRA device placement surgery. During the procedure, the previous incision was opened and the healing components were removed from the bone. The abutment scre...
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A 75-year-old patient had previously undergone creation of a tracheostomy that was subsequently taken down. Since that time, the tracheostomy site has remained open with greenish discharge without ...
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A patient with a history of acute subdural hematoma secondary to a motor vehicle accident previously underwent hemicraniectomy followed by cranioplasty using autologous bone flap. On a follow-up ex...
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This same patient presented for removal of their autologous bone flap to allow the site to heal for placement of a synthetic cranioplasty implant at a later time. At surgery, an incision was made a...
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