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A patient with metastatic bone cancer of the left hip is admitted to undergo acetabular reconstruction with hip replacement. At surgery the proximal femur was prepared using sequential reamers and ...
Due to the s...
The patient was diagnosed with a synovial sarcoma stage III chest mass during pregnancy, and treatment was started at that time. The patient is two weeks post-delivery, and is now being admitted fo...
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Does documentation of a positive Coombs test need to be present in order for the diagnosis code for ABO isoimmunization to be assigned on a newborn record?
...No. If the p...
A newborn is diagnosed with congenital hyperbilirubinemia, likely hemolytic. A positive Coombs test is also documented. What is the correct code assignment for the newborn?
...This appears...
The physician documents “suspected sepsis” in a preterm newborn and treats the newborn with antibiotics for two days. The blood cultures are negative and sepsis is ruled out. The mother is with...
There is no ...
A patient with diabetes mellitus was admitted when she was found to be lethargic. Her blood sugar readings were low. Discharge diagnosis was documented as acute encephalopathy secondary to hypoglyc...
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How is immunocompromised state due to medication or other cause (e.g., AIDS, cancer) coded? The physician documented in the discharge summary that the “patient has an immunocompromised state, on ...
Do not assig...
When the physician documents in his final diagnostic statement “Immunocompromised State” and it is not caused by medication or due to an underlying disease process, should immunocompromised sta...
Yes, assign ...
How would an immunocompromised state be coded when the intent of a medication is to treat the underlying disease and not alter the immune state?
...This situati...
What is the correct code assignment, when a patient is admitted for desensitization to a medication? For example, a patient with chronic respiratory conditions is currently symptomatic and recent s...
There is no ...