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The Official Guidelines for Coding and Reporting, Section I.C.16.a.2, states that “A code from category Z38 is assigned only once, to a newborn at the time of birth. If a newborn is transferred t...
For physicia...
When assigning the ICD-10-CM code for heart failure, based on the Index, only code I50.9, Heart failure, unspecified, is reported. There are no instructions in the Index or Tabular at category I50,...
Code J91.8, ...
What is the correct ICD-10-CM code assignment for a patient who presents with an acute non-ST elevation myocardial infarction, and develops post-infarctional angina when the patient also has athero...
Assign code ...
The patient was diagnosed with acute liver injury as well as acute hepatitis, nonviral. Code S36.119, Unspecified injury of liver, does not seem to apply since there was no documentation of a traum...
Code the exa...
Can individual Glasgow coma score (GCS) codes be assigned based on documented numeric values rather than the description of the codes (e.g., eyes open to pain, best verbal response, etc.)?
Yes, if the ...
A patient with painful right total knee arthroplasty presents for revision of the arthroplasty. The previous components were removed and new tibial and femoral components were inserted and cemented...
Since the co...
The patient was admitted for revision of right hip arthroplasty. The right ceramic head and acetabular liner were replaced due to excessive wear. Is this procedure coded as a revision or replacemen...
When the com...
A patient with cervical stenosis presented for laminoplasty of levels C3-C7. The patient was prepped for surgery and a midline posterior cervical incision was made. A drill was used to create a &nb...
In this case...
The patient is an 83-year-old male who presented with cervical myelopathy. He elected to proceed with decompressive cervical laminectomy to release the spinal cord. The surgeon performed an open to...
The laminect...
A patient presents with left frozen shoulder with subacromial impingement, biceps tendonitis, and rotator cuff tendonitis. He underwent left shoulder manipulation, arthroscopic subacromial decompre...
The objectiv...