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A patient is admitted to the hospital with syncope. The provider’s final diagnostic statement lists “End stage renal disease (ESRD) due to congenital polycystic kidney disease.” The provider ...
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A 51-year-old male with a history of nephrolithiasis presents due to severe right flank pain and nausea and vomiting. A CT scan was performed in the emergency department which showed two stones tog...
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The patient presents to the Emergency Department (ED) and is admitted with a gunshot wound with retained bullet fragments of the right lower leg after being assaulted. The gunshot injury did not fr...
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For inpatient cases, coders are expected to query the physician if there is conflicting information between the medical record final diagnosis and the pathology report. However, if a patient is adm...
The ICD-10-C...
This patient is admitted for replacement of a gastrostomy tube. The tube was malfunctioning (continuously falling out) and was ultimately left out over a period of time. The gastrostomy stoma essen...
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A patient who is status post liver transplant was admitted for exploratory laparotomy due to intraperitoneal bleeding. A redo of the bile duct anastomosis was performed due to questionable leaking....
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A patient with abnormal liver function test and acute pancreatitis suspected of being due to gallstones, underwent endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and panc...
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A patient diagnosed with recurrent airway obstruction secondary to prolapsing epiglottis underwent surgical repair. The provider performed an endoscopic lingual tonsillectomy and tongue base excisi...
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A patient with history of bilateral cleft lip and palate was seen for closure of bilateral patent alveolar clefts. The surrounding scar tissue was mobilized at the left-sided cleft to create a pock...
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The patient is a 14-year-old male with known quadriplegic-pattern cerebral palsy and bilateral hip dislocations with degenerative changes. The patient is admitted to undergo resection arthroplasty ...
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