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The patient presents for cleft lip repair, and underwent Millard technique, which consisted of rotating the medial segment and advancing the lateral flap. The Cupids bow with piltrum is preserved w...
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The patient had previously undergone a Mitrofanoff procedure and now presents with Mitrofanoff channel polyps. The polyps were excised via cystourethroscope, and the surgeon documented “three fai...
For the exci...
A 19-year-old patient, status post ileal conduit urinary diversion surgery, developed tortuosity and kinking of the left ureter due to recurrent urinary tract infection. At surgery, the left ureter...
This patient...
A patient had insertion of a Swan Ganz catheter for monitoring of pulmonary artery pressure. Are two codes assigned to describe both the catheter insertion and pressure monitoring? Additionally, is...
When a Swan ...
An 84-year-old patient was admitted to our long-term care hospital (LTCH) for posttraumatic subarachnoid hemorrhage and subdural hematoma. She was treated medically at an acute care facility and wa...
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Surgical treatment is provided in the Official Coding Guidelines as an example of active treatment for the selection of the 7th character for initial encounter for codes in Chapter 19. If a patient...
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The patient presents for surgical treatment of a malunion of a fracture of the humeral greater tuberosity. This is the first time the malunion is being surgically treated, and the patient did not d...
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The patient had previously undergone open reduction internal fixation of a fracture. Three days post-discharge the patient is readmitted due to pain at the fracture site. An x-ray noted improper al...
The patient ...
When a Rh negative mother delivers at term without complication, and she is administered Rhogam prophylactically during the admission, would code Z31.82, Encounter for Rh incompatibility status, be...
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