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When coding the diagnosis of breast conditions and the physician documents the location in terms such as positions on a clock, is it appropriate to code to the associated breast quadrant? For examp...
Facilities m...
Coma scale codes R40.2110 - R40.2364 reflect various coma levels for eyes open, best verbal and motor response. Our pediatric coma scores are based on auditory/visual stimuli, agitated, persistent ...
Inclusion te...
The patient had left ventricular outflow tract obstruction due to a subaortic membrane as well as tubular hypoplasia of the area. Following sternotomy and aortotomy, the aortic valve leaflets were ...
In this case...
A patient with a pulmonary arteriovenous fistula presented for embolization of the right middle lobe lesions. Tornado coils were deployed into the right pulmonary artery that fed into a branch of t...
The procedur...
In a patient with severe congenital mitral valve regurgitation, a suture was placed to create an Alfieri stitch bringing together the center A2 segment of the anterior leaflet and the center P2 seg...
Assign the f...
A patient with hypoplastic left heart syndrome who is status post Norwood procedure and bidirectional Glenn procedure now presents for the Fontan completion procedure. The inferior vena cava was di...
Assign code ...
A patient undergoes outpatient surgery. A skin lesion of the cheek is surgically removed and submitted to the pathologist for analysis. The surgeon writes on the pathology order, “skin lesion.”...
The patholog...
A patient presents to the hospital for outpatient x-rays with a diagnosis on the physician’s orders of questionable kidney stone. The abdominal x-ray reveals “bilateral nephrolithiasis with sta...
It is correc...
A patient undergoes outpatient surgery for removal of a right breast mass. The pre- and post-operative diagnosis is reported as “breast mass.” The pathological diagnosis is fibroadenoma. How sh...
The facility...
A referring physician sends a urine specimen to the cytology lab for analysis with a diagnosis of “hematuria” (code R31.9). However, the cytology report, which is authenticated by the pathologi...
The laborato...