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A patient, who is diagnosed with a stage IV sacral decubitus ulcer and wet gangrene, underwent excisional and nonexcisional debridement, down to and including muscle, fascia, and bone. Since debrid...
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A patient presents with a painful knee, status post right total knee replacement. In the operative suite, arthroscopic manipulation of the right knee was performed under anesthesia to break up the ...
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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 ...
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When the provider documents “sepsis due to aspiration pneumonia,” is a code for the sepsis, or the aspiration pneumonia assigned as the principal diagnosis?
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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 patient was admitted to day surgery for a biopsy of a neck mass. Following the biopsy, the patient continued to complain of neck pain and was admitted to observation for continued monitoring. ...
The reason f...
A patient was seen in the emergency department for complaints of chest pain. Nitroglycerin was given sublingually, however, the chest pain did not resolve. The patient’s cardiac enzymes were slig...
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