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A patient, who has Grade III L5/S1 anterior spondylolisthesis with right leg sciatica, presents for surgical treatment consisting of laminectomy, posterior lumbar decompression, non-segmental poste...
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A patient who had previously undergone total proctocolectomy with continent ileostomy (Kock pouch) presents for revision of the K-pouch due to leakage. Upon entering the abdomen, the surgeon noted ...
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A patient presented for biopsy of the rectum. During the procedure, a rectal suction biopsy gun was loaded with specimen capsules and advanced through the anus. Two samples were obtained from the p...
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A patient with mucosal melanoma involving the left maxillary alveolus and sinus is admitted for left maxillectomy with obturator reconstruction. The surgeon proceeded with an inferior and anterior ...
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A male patient presents for surgical treatment of ulcerative colitis refractory to medical therapy. Laparoscopic restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) is performed....
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What is the appropriate diagnosis code assignment for anti-neutrophil cytoplasmic autoantibody (ANCA) vasculitis with nephritic syndrome?
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A patient presents to the hospital for treatment of an exacerbation of cystic fibrosis (CF) and bronchiectasis. Our physicians state that bronchiectasis is common in CF, and that the admission is f...
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A patient presents with a sacral deep tissue injury (DTI), and undergoes surgical debridement. Following excisional debridement, the provider documents “Stage 4 pressure ulcer of the sacrum.” S...
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The provider documented both mild cognitive impairment and unspecified degenerative disease of the nervous system on the same encounter. The Excludes1 note at code G31.84, Mild cognitive impairment...
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The provider documented both colitis and diarrhea on the same encounter. At code K52.9, Noninfective gastroenteritis and colitis, unspecified, there is an Excludes1 note that references code R19.7,...
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