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A patient with multiple spinal conditions, including previous fusion, severe kyphoscoliosis, and severe spinal and foraminal stenosis, presents for corrective surgery. Prior fusion instrumentation ...
Do not assig...
When the provider documents “sepsis due to aspiration pneumonia,” is a code for the sepsis, or the aspiration pneumonia assigned as the principal diagnosis?
...Assign code ...
A patient was discharged with the following diagnoses: 1. sepsis secondary to aspiration pneumonia, 2. aspiration pneumonia secondary to probable gram-negative bacteria. Both diagnoses were present...
When sepsis ...
An 84-year-old male with chronic gait instability is admitted after a fall. The provider’s documentation states that the patient’s gait instability is related to chronic cerebrovascular acciden...
Although the...
A patient with twin pregnancy presented with Twin A in a frank breech position too low in the vagina for a cesarean section. The decision was made for a vaginal breech delivery. The head of Twin A ...
The purpose ...
A patient, who had suffered a traumatic brain injury (TBI) without loss of consciousness secondary to a high-speed motor vehicle accident, developed brain herniation. There is an Excludes1 note tha...
If the physi...
This is a 53-year-old male who is seen in the emergency department (ED) after a fall. The patient was evaluated and x-rays were ordered. On review of the x-rays the emergency department physician d...
29125-LT—A...
This patient is a 65-year-old female who presents to the hospital orthopedic outpatient clinic for a one-week follow-up of a displaced right patella. The right long-leg cast was removed due to poor...
Assign the f...
This 39-year-old patient was seen in the emergency room with complaints of stabbing pain at her elbow. She stated that while reaching to catch her 3-year-old son falling from a chair she felt a sta...
Assign the f...
Can you code a screening mammogram for a patient that has had a mastectomy on one side, and it is documented in the record that the mammogram was unilateral, by appending modifier -52 to code 76092...
Code 76092 f...