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The Glasgow coma scale (GCS) is used to help evaluate the acuity of traumatic brain injuries. Therefore, would it be appropriate to report the most severe GCS score if the patient’s score worsens...
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A patient with traumatic subarachnoid hemorrhage and traumatic subdural hemorrhage due to a fall was initially noted to have loss of consciousness (LOC), for approximately 30 minutes at the time of...
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A 50-year-old patient with a history of human immunodeficiency virus (HIV) disease presented after experiencing blurry vision for the past two weeks. The patient was admitted and after work-up, the...
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A patient with a history of T-cell lymphoma of the skin presented due to fever, hypotension and worsening skin lesions. A positron emission tomography (PET) scan was performed which showed multiple...
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A patient with a known history of a carotid body tumor is admitted for surgical treatment of a left infrarenal para-aortic mass consistent with a paraganglioma. During the procedure, an incision wa...
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A 79-year-old patient is diagnosed with secondary hypercoagulable state and has a history of paroxysmal atrial fibrillation (AF) on anticoagulant maintenance. Does the provider need to link the sec...
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A 76-year-old male with persistent atrial fibrillation (AF) on anticoagulant therapy presented for follow-up. The provider listed “Hypercoagulable state” in the diagnostic statement. However, h...
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The patient was diagnosed with chronic bilateral subsegmental pulmonary emboli (PE). In the Alphabetic Index under Embolism, pulmonary, there are separate subentries at the same indentation level f...
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What is the appropriate ICD-10-CM code for granulomatosis with polyangiitis, without documented Wegener’s granulomatosis?
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An obese woman, who is 40 weeks gestation, had a normal delivery of a healthy infant. The provider noted “Obesity” in his final diagnostic statement. There is a note in the Tabular List instruc...
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