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A patient presents to the physician’s office for an annual check-up and is noted to have received the first dose of a two-dose regimen (e.g., Moderna) COVID-19 vaccine, but has not received the s...
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According to the updated guideline B4.1c, if a carotid endarterectomy is performed on a single continuous lesion involving both the common carotid artery and internal carotid artery, the common car...
The procedur...
The updated ICD-10-PCS Official Guidelines for Coding and Reporting, Guideline B4.1c, pertaining to procedures performed on a continuous section of a tubular body part appears to conflict ...
The updated ...
A 51-year-old patient with severe protein calorie malnutrition due to extreme anorexia nervosa, binge-eating purging type, is admitted to the hospital for stabilization of her acute medical conditi...
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A 44-year-old presents with a palpable mass in the upper quadrant of the left breast. The patient underwent wide excision of the left breast mass, diagnostic left axillary lymphadenectomy, therapeu...
Yes, the roo...
The patient is a 38-year-old with a history of left breast malignancy (Her2-negative) status post modified left radical mastectomy, antineoplastic and radiation therapy. She has previously undergon...
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A patient with central nervous system 1a, B-cell acute lymphoblastic leukemia (B-ALL) is admitted for intrathecal consolidation chemotherapy. Immediately following chemotherapy, per protocol, an en...
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A newborn delivered at term with Apgar scores of 9 and 9, was monitored for withdrawal symptoms due to intrauterine exposure of prescribed maternal Subutex®. Neonatal abstinence syndrome (NAS) mon...
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A 39-week old infant was born via spontaneous vaginal delivery to a mom who had a history of marijuana use, and subsequently stopped using once she found out about the pregnancy. Because of the his...
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Quality measures at our facility may be affected when a patient is receiving palliative care and the present on admission (POA) indicator “N” (No) is reported. We are seeking official guidance ...
Effective Oc...