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When the provider documents “sepsis due to aspiration pneumonia,” is a code for the sepsis, or the aspiration pneumonia assigned as the principal diagnosis?
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A patient was discharged with the following diagnoses: 1. sepsis secondary to aspiration pneumonia, 2. aspiration pneumonia secondary to probable gram-negative bacteria. Both diagnoses were present...
When sepsis ...
An 84-year-old male with chronic gait instability is admitted after a fall. The provider’s documentation states that the patient’s gait instability is related to chronic cerebrovascular acciden...
Although the...
A patient with twin pregnancy presented with Twin A in a frank breech position too low in the vagina for a cesarean section. The decision was made for a vaginal breech delivery. The head of Twin A ...
The purpose ...
A patient, who had suffered a traumatic brain injury (TBI) without loss of consciousness secondary to a high-speed motor vehicle accident, developed brain herniation. There is an Excludes1 note tha...
If the physi...
A patient is admitted to the operating room for a proctoplasty and hemorrhoidal artery ligation with ultrasound guidance. According to the operative report, an anoscope was utilized and the artery ...
Report CPT c...
Patient with hallux rigidus presents for correction of the right metatarsophalangeal joint (MPJ) with hemi-implant insertion. Deep incision was made exposing the metatarsal head and base of the pro...
Based on the...
A patient was seen at our facility with a history of status post cardiac pacemaker. Her complaint is focal tenderness in the pocket area overlying the site of the lead suture sleeves. Due to the te...
Although the...
Patient with history of spermatocele and hydrocele repair, presents with pain, swelling, and a large mass in the left hemiscrotum. A 10-12 cm scrotal hematoma and necrotic skin measuring 1cm x 8cm ...
Assign CPT c...
Patient presents to have whole body SPECT/CT images done at 4 hours and images of the chest done at 24 hours due to a history of neuroendocrine cancer. Would it be appropriate to report 2 units for...
Currently, t...