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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 in acute respiratory failure, and was intubated and placed on mechanical ventilation for 23 hours. Should the endotracheal (ET) intubation be separately coded along with the ...
Yes, in this...
A patient status post tracheostomy was admitted as an inpatient on mechanical ventilation. Five days later the tracheostomy was removed and the patient was successfully weaned off of the ventilator...
All of the p...
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...
A five-year-old presents with a rib deformity associated with congenital scoliosis affecting the thoracic region with thoracic insufficiency. The patient underwent open placement of vertical expand...
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