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A patient presents with bleeding duodenal ulcer and an esophagogastroduodenoscopy was carried out. Multiple clips were applied to the vessels to control the multiple hemorrhaging ulcers. Should “...
The root ope...
The patient presented with epistaxis and the provider documented that two sutures were placed to surround a small ruptured arterial bleeding vessel of the external right naris. Since the purpose of...
This procedu...
A patient with a known history of pulmonary hypertension, chronic obstructive pulmonary disease and cor pulmonale presents with new-onset shortness of breath, increasing peripheral edema and severe...
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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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A patient was admitted for right hip hemiarthroplasty due to femoral neck fracture. While in the post-anesthesia care unit, postoperative radiographs revealed a loose cement fragment in the joint. ...
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A patient presents to our facility for evaluation of left hip and groin pain discomfort. Arthroscopy was performed which revealed left hip femoroacetabular impingement with symptomatic labral tear ...
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This same patient underwent repair of the femoroacetabular impingement and labral tear. An arthroscopy was initiated and an intraportal capsulotomy and synovectomy was performed along with shaving ...
The labral r...