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Surgical treatment is provided in the Official Coding Guidelines as an example of active treatment for the selection of the 7th character for initial encounter for codes in Chapter 19. If a patient...
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The patient presents for surgical treatment of a malunion of a fracture of the humeral greater tuberosity. This is the first time the malunion is being surgically treated, and the patient did not d...
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The patient had previously undergone open reduction internal fixation of a fracture. Three days post-discharge the patient is readmitted due to pain at the fracture site. An x-ray noted improper al...
The patient ...
When a Rh negative mother delivers at term without complication, and she is administered Rhogam prophylactically during the admission, would code Z31.82, Encounter for Rh incompatibility status, be...
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One of the examples on the use of the 7th character published in the First Quarter 2015 issue of Coding Clinic page 8 indicated that “the activity code is not assigned again as activity codes are...
Yes, “init...
A patient is admitted to the hospital for delivery following premature rupture of the membranes. During the delivery, the patient suffers a laceration (first, second or third degree). Is the princi...
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A 39-year-old pregnant patient is admitted for induction secondary to polyhydramnios and delivers vaginally. During delivery she suffers a second degree tear, which is repaired. Is the principal di...
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The patient is admitted in labor. She has gallstones and anemia on admission and the physician has not documented that these conditions did NOT affect the pregnancy. She delivers vaginally but deve...
Since both c...
The patient had no complications during pregnancy, and is admitted in labor. She delivers a healthy liveborn infant. However, the patient experiences a periurethral laceration during delivery that ...
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A 41-week pregnant patient was admitted in labor. Her pregnancy is complicated by gestational diabetes mellitus and post-term status. The patient delivers and suffers a second degree perineal lacer...
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