A patient came into the ED following a car accident. Examina…

A patient came into the ED following a car accident. Examination revealed the following: Vitals: Temperature 98.8; Respirations 24, shallow; BP 101/54; GCS 13. The ED doctor noted the patient would open her eyes to pain, but as the examination continued and questions were asked, the patient responded with inappropriate words. It was also noted that the patient had abnormal flexion. The patient had a CT scan of the head, since a large gash was seen on the forehead, and a subdural hematoma was identified. What discrepancy is noted in this documentation?

A patient comes in for an outpatient EGD with biopsy. While…

A patient comes in for an outpatient EGD with biopsy. While in recovery following the procedure, the patient begins complaining of severe chest pain and is taken to the cardiac catheterization lab. A left heart catheterization with coronary angiography is performed and a stent is inserted into the left circumflex artery. Additionally, an atherectomy of the left anterior descending artery is performed. The patient is placed in observation overnight and discharged the next day. What CPT procedure code(s), sequencing, and modifiers apply?

A patient is admitted with chest pain. Labs and EKG indicate…

A patient is admitted with chest pain. Labs and EKG indicate an acute inferior wall MI. Home medications include furosemide, insulin, and rosuvastatin. Documentation in the H&P notes the patient’s history of type 1 diabetes and hyperlipidemia. During hospitalization weight gain was noted along with swelling of the lower legs and reduced ejection fraction. Furosemide dosage was increased. Which of the following diagnoses might the lead the coding professional to query the attending physician?