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A patient presented to the ED with a complaint of left flank tenderness for three days. The patient denied dysuria, hematuria, or penile pain. Physical exam was remarkable for tenderness of the lef...
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A patient was admitted due to a 4-day history of intractable nausea and vomiting. The patient was not able to keep food down and could only drink very little liquids. The physician noted that the p...
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A 37-year-old patient was admitted for debridement of chronic ulcers of the right and left forearms. The ulcers expressed a copious purulent discharge with areas of necrosis of the subcutaneous tis...
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A patient with a left lateral chest wound (a sutured mini thoracotomy incision) underwent V.A.C.® ULTA negative pressure wound therapy (NPWT) without instillation to prevent infection, manage woun...
Yes. Assign ...
A patient with recurrent multifocal glioblastoma was admitted for tumor destruction via focused ultrasound sonodynamic therapy. Several hours prior to the procedure, the patient was infused periphe...
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A patient is diagnosed with hyperlipidemia associated with type 2 diabetes mellitus. Is hyperlipidemia considered a specified type of diabetic manifestation? What is the correct code assignment?
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A patient presented for a 6-month follow-up visit for type 2 diabetes and hypertension. The patient’s diabetes was documented as being well-controlled. Provider documentation also indicated “mi...
Diabetic mic...
A 39-year-old patient was admitted at 38 weeks and 5 days gestation with spontaneous rupture of membranes (SROM). Pitocin augmentation was administered, and the patient progressed to complete cervi...
SROM occurri...
Many patients present with depression and dementia without documentation of a relationship by the provider. We understand the presumed linkages in the classification with the subterm “with,” ho...
The classifi...
A patient seen in the outpatient setting was noted to have dementia, anxiety, and depression. Assuming that these conditions meet reporting requirements, are they coded as related based on the “w...
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