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A patient underwent a laparoscopic cholecystectomy. During the procedure, the gallbladder was dissected out of the liver bed with electrocautery and removed. FloSeal was used on a small bleeder fro...
No, do not a...
A patient underwent a laparoscopic cholecystectomy. After removal of the gallbladder, a small amount of bleeding in the liver bed had to be controlled. We believed that this was integral to the cho...
Control of t...
What is the correct ICD-10-CM code assignment for catecholaminergic polymorphic ventricular tachycardia (CPVT)?
...Assign code ...
A patient underwent distraction osteogenesis for cranio-synostosis. An osteotomy was performed to gain access to the area to be distracted. Segments of soft spots were roughed up with placement of ...
A cranial di...
The patient had a depressed comminuted open right frontal bone fracture and underwent open reduction and internal fixation of fracture and primary repair of dural rent. The patient was found to hav...
For the proc...
A patient diagnosed with stenosis and degenerative spondylolisthesis underwent a 360-degree fusion. The provider documented Crescent PEEK interbody device, locally harvested autograft bone, some al...
Assign the f...
With the thoracic aortic valve repair (TAVR) procedures, the surgeons will document left heart cardiac catheterization. Occasionally they will mention a pressure or two, but no report that an actua...
TAVR is a mi...
Is there a guideline or rule that indicates that you should only use the medical record documentation for that specific visit/admission for diagnosis coding purposes? Does each visit or admission s...
Documentatio...
How is a total hysterectomy performed via an open approach coded? Is it appropriate to assign ICD-10-PCS codes for both the resection of the uterus and the cervix, when only a total hysterectomy is...
For a total ...
A patient, who had previously undergone modified radical mastectomy due to breast cancer, presented for insertion of a left breast tissue expander. The tissue expander was inserted into an expander...
For the plac...