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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?
...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...
We are concerned about the NCCI edit for codes 77401-77416 for radiation treatment sessions. At our facility radiation treatment may be delivered to more than one area during a single session. How ...
It is approp...
A 14-year-old patient was brought to the emergency department with severe pain and swelling of his left ankle. He sustained an injury when he fell off his skateboard on the school playground. A 2-v...
Report code ...
This 10-year-old boy was struck by an automobile while riding his bicycle in the street. He suffered an open fracture of the shaft of the left tibia and fibula. The patient was scheduled for ambula...
Report code ...
We are concerned about the NCCI edit for codes 77401-77416 for radiation treatment sessions. At our facility radiation treatment may be delivered to more than one area during a single session. How ...
It is approp...
Radiation therapy treatments are provided at our outpatient hospital facility. A question has recently surfaced among our staff regarding the reporting of treatment management services (77427-77431...
The hospital...