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An obstetric patient presents due to “contractions” at 37 weeks gestation. During the encounter, the provider noted “No vaginal bleeding or rupture of membranes.” The patient was released, ...
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When the provider’s documentation indicates a patient has both depression and anxiety by using terminology such as depression and anxiety or depression with anxiety, are these diagnoses coded sep...
The classifi...
In the outpatient setting, the provider documented gastrointestinal (GI) bleeding likely due to gastric ulcer and diverticulosis. Although the provider confirmed the gastric ulcer and diverticulosi...
In the outpa...
A patient diagnosed with asthma is currently on prescribed inhaled albuterol, “as needed” for control of symptoms. Since the medication is prescribed for long-term treatment of asthma, would it...
Medications ...
A 70-year-old patient with a history of nonalcoholic steatohepatitis (NASH) cirrhosis complicated by hepatic encephalopathy and diabetes presented to the emergency department (ED) secondary to alte...
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A 71-year-old patient with multiple vessel coronary artery disease and severe aortic valve stenosis underwent coronary artery bypass graft (CABG) surgery and aortic valve replacement (AVR). Followi...
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A patient undergoes surveillance upper gastrointestinal (GI) endoscopy due to a personal and family history of familial adenomatous polyposis (FAP). The endoscope is introduced into the mouth and a...
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The patient had calcified plaque involving the entire common femoral artery, extending into bilateral distal external iliac arteries, with stenotic lesions in the profunda femoris and superficial f...
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A patient with aortic stenosis underwent transcatheter aortic valve replacement (TAVR). Prior to the TAVR, one filter of a dual filter Sentinel™ Embolic Protection Device was deployed in the inno...
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A patient presented with an infected right total ankle replacement. At surgery, the components of the previous total ankle replacement were exposed. The tibial polyethylene was disengaged from the ...
The tibial p...