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Pancytopenia is defined as the presence of anemia, neutropenia, and thrombocytopenia. When a patient has anemia, neutropenia, and thrombocytopenia, would it be appropriate to assign a code fo...
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A patient, who was diagnosed with cauda equina syndrome from L3-L4 and L4-L5 epidural hematoma, status post L3-L5 bilateral decompression laminectomy, underwent evacuation of the hematoma with addi...
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A patient with an ileal conduit neobladder is admitted with fever and abdominal discomfort due to acute pyelonephritis. A query to the provider clarified recurrent acute pyelonephritis secondary to...
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When a patient is admitted and is diagnosed with both cardiac arrest and cardiogenic shock, how is this coded?
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A 68-year-old male was taken to the emergency department and admitted as an inpatient, after an abrupt development of shortness of breath. In the final diagnostic statement, the provider listed, ...
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A 64-year-old patient with an extensive medical history was admitted for a full work up due to bloody diarrhea. The provider’s final diagnostic statement listed, “IgA mediated leukocytoclastic ...
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We are seeking advice on how to code lacunar stroke when the patient also has carotid stenosis. Our clinicians state that lacunar infarcts result from small vessel brain disease and are never relat...
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The patient presented with bilateral carotid artery occlusion and acute right middle cerebral artery (MCA) infarction. The provider documented that friable stenotic plaque in the right carotid arte...
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A patient, who is status post glaucoma surgery due to bilateral primary open angle glaucoma, presented for an office visit. The provider’s diagnostic statement listed “Recurrent Seidel positive...
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A patient, who was diagnosed with an infiltrating ductal carcinoma of the right breast of overlapping sites, presents for an outpatient follow-up visit after previously undergoing an excisional lum...
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