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An adult patient presented for left inguinal hernia repair. The patient was taken to the operating room where a left groin incision was made. Dissection was carried down through Scarpa’s fasc...
In this case...
A patient with a personal history of rectal cancer and status post abdominoperineal resection presents for a colonoscopy for cancer surveillance. The colonoscopy was performed through the sigmoid s...
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A patient diagnosed with an anterior cruciate ligament (ACL) tear with risk factors for re-tear presents for definitive treatment. The quadriceps tendon was harvested; the femoral aspect measured 9...
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A patient with rectal cancer metastatic to the liver presented for mesenteric arteriography mapping for future Yttrium-90 microsphere radioembolization. Under moderate sedation, selective superior ...
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A patient is diagnosed with hyperlipidemia associated with type 2 diabetes mellitus. Is hyperlipidemia considered a specified type of diabetic manifestation? What is the correct code assignment?
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A patient presented for a 6-month follow-up visit for type 2 diabetes and hypertension. The patient’s diabetes was documented as being well-controlled. Provider documentation also indicated “mi...
Diabetic mic...
A 39-year-old patient was admitted at 38 weeks and 5 days gestation with spontaneous rupture of membranes (SROM). Pitocin augmentation was administered, and the patient progressed to complete cervi...
SROM occurri...
Many patients present with depression and dementia without documentation of a relationship by the provider. We understand the presumed linkages in the classification with the subterm “with,” ho...
The classifi...
A patient seen in the outpatient setting was noted to have dementia, anxiety, and depression. Assuming that these conditions meet reporting requirements, are they coded as related based on the “w...
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A patient had a final diagnosis of moderate dementia with disturbance of behavior and psychotic disorder with hallucinations. Is it appropriate to link dementia to disturbance of behavior and psych...
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