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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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Does the medical documentation have to state “old CVA” in order to use the sequelae (I69) codes for the LTC admission?
...No, there is...
A patient is admitted to the LTC facility following treatment of an acute CVA. The patient made a complete recovery from the CVA. She was diagnosed with progressive senile dementia, coronary artery...
Any of the c...
The patient is transferred to LTC for physical therapy following a hospitalization for treatment of an acute pelvic and clavicular fracture. How should the LTC stay be coded?
...When a patie...
A patient is admitted to LTC following hospital treatment of a fracture of the right femur. The reason for the LTC admission is to allow the patient to regain strength and the fracture to heal. Wha...
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A resident in LTC facility develops a urinary tract infection (UTI), which is treated and resolved during the LTC stay. Should the UTI be coded?
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A resident returns to the LTC facility following hospital care for pneumonia. The physician’s orders state, “continue IV antibiotics for 3 days,” after which time the resident is to have a re...
Yes, the pne...