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A patient presents with possible recurrent E. coli urinary tract infection, bacteremia and ongoing left hip/groin pain. A pubic symphysis aspirate demonstrated E. coli, likely the same E. coli in t...
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This same patient underwent an aspiration fluid biopsy of the pubic symphysis joint. During the procedure, a guide needle was passed percutaneously under CT guidance into the pubic symphysis joint....
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A six-year-old with gross motor function classification system (GMFCS) 5 spastic quadriplegic cerebral palsy (CP), who has had progressive subluxation of both hips, presents for surgical interventi...
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A patient presents due to spontaneous rupture of the left eye globe, which required emergency surgery. The patient underwent an enucleation with subsequent implant of the left eye. There is no ment...
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A patient was admitted for treatment of a malleolus fracture of the right ankle. The provider documented “Alcohol abuse - monitor for withdrawal symptoms.” The patient also had a history of anx...
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Should combination codes be assigned from categories F10-F19, Mental and behavioral disorders due to psychoactive substance use, any time a patient with a substance abuse or dependence diagnosis al...
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A patient with a history of traumatic brain injury, status post bilateral craniectomies is admitted for skull reconstruction due to bilateral frontoparietal cranial defects. Cranioplasty was perfor...
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A patient presents to the Emergency Department (ED) with abdominal pain, chills, and severe low back pain, after not being able to retrieve a tampon used for menstruation. After admission, the work...
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A patient stopped taking his prescribed dose of Amlodipine after running out of the antihypertensive medication several days ago. The provider documented that the patient’s blood pressure was sta...
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My facility has interpreted new HIV coding guideline I.C.1.a.2.i “History of HIV managed by medication” to mean that code B20, HIV disease, should be reported for any HIV positive patient on an...
The intent o...