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For inpatient cases, coders are expected to query the physician if there is conflicting information between the medical record final diagnosis and the pathology report. However, if a patient is adm...
The ICD-10-C...
This patient is admitted for replacement of a gastrostomy tube. The tube was malfunctioning (continuously falling out) and was ultimately left out over a period of time. The gastrostomy stoma essen...
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A patient who is status post liver transplant was admitted for exploratory laparotomy due to intraperitoneal bleeding. A redo of the bile duct anastomosis was performed due to questionable leaking....
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A patient with abnormal liver function test and acute pancreatitis suspected of being due to gallstones, underwent endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and panc...
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A patient diagnosed with recurrent airway obstruction secondary to prolapsing epiglottis underwent surgical repair. The provider performed an endoscopic lingual tonsillectomy and tongue base excisi...
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A patient with history of bilateral cleft lip and palate was seen for closure of bilateral patent alveolar clefts. The surrounding scar tissue was mobilized at the left-sided cleft to create a pock...
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The patient is a 14-year-old male with known quadriplegic-pattern cerebral palsy and bilateral hip dislocations with degenerative changes. The patient is admitted to undergo resection arthroplasty ...
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The patient presented for a left femoral to peroneal artery bypass. After several attempts to find a suitable vein, it was determined that the greater saphenous would have to be utilized as an in-s...
Use of the s...
A patient with severe tricuspid regurgitation and right-sided systolic heart failure was admitted for transcatheter tricuspid valve replacement using bovine bioprosthesis. When referencing table 02...
The ICD-10-P...
A female patient diagnosed with tear of the subscapularis tendon, biceps tendonitis, subacromial and subcoracoid impingement, underwent arthroscopic rotator cuff repair of the subscapularis tendon,...
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