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A patient with multiple spinal conditions, including previous fusion, severe kyphoscoliosis, and severe spinal and foraminal stenosis, presents for corrective surgery. Prior fusion instrumentation ...
Do not assig...
When the provider documents “sepsis due to aspiration pneumonia,” is a code for the sepsis, or the aspiration pneumonia assigned as the principal diagnosis?
...Assign code ...
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 Medicare patient was seen for a scheduled audiologic function test at our facility. On examination, impacted cerumen was noted in both ears. The impacted cerumen was removed via ear curettes bila...
For Medicare...
A Medicare patient was seen for the removal of impacted cerumen in both ears. The cerumen was removed by irrigation with a saline solution. Since this procedure was performed on both ears would it ...
Yes, you may...
Patient presents to have a mass of the left breast and a left axillary lymph node biopsied. The left breast nodule was identified and via direct sonographic guidance the needle was inserted and two...
Assign CPT c...
Patient presents for excision of a pressure wound from the below-knee amputation (BKA) stump. Electrocautery was used to excise the wound and again to undermine the wound edges. The skin in the are...
Based on the...