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The patient became unresponsive after receiving intravenous Dilaudid. The provider documented “Unresponsiveness due to Dilaudid.” How is this diagnosis coded?
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A 15-year-old male presented with a growing mass on the right side of his head. After diagnostic workup, the provider documented “Craniofacial deformity secondary to leptomeningeal cyst/growing s...
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A patient is admitted for transoral Zenker’s diverticulectomy. During surgery, the scope was positioned, and an endovascular gastrointestinal stapler was passed transorally with the staple load i...
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A patient, who is diagnosed with a stage IV sacral decubitus ulcer and wet gangrene, underwent excisional and nonexcisional debridement, down to and including muscle, fascia, and bone. Since debrid...
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A patient presents with a painful knee, status post right total knee replacement. In the operative suite, arthroscopic manipulation of the right knee was performed under anesthesia to break up the ...
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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 ...
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When the provider documents “sepsis due to aspiration pneumonia,” is a code for the sepsis, or the aspiration pneumonia assigned as the principal diagnosis?
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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 ...