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    I would agree with 790.92 for abnormal coagulation profile; however, you also need to look at the scenerio. Did the patient take the medication as prescribed or not? When the anticoagulant therapy is correctly prescribed and properly administered, but a patient experiences an adverse effect...
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    Inability to Ambulate

    You have to look at the reason why the pt can not ambulate. Category 719.x describes disorders of the joints. If the pt can not ambulate due to weakness 719.7 would not be appropriate.
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    DX code from EKG interpretation

    I am auditing some ED records and struggling if this is appropriate or not. Patients that come in with chest pain and the provider orders an EKG. There is a signed machine-generated EKG tracing in the record. It is appropriate to assign the diagnosis, such as Incomplete RBBB or abnormal ECG...
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    An ED case that I'm struggling with

    There is no distinction between "new" and "established" patients in the ED. See the first paragraph of the CPT book under Emergency Department Services. It is not part of the code descriptor for 99281-99285. There are three types of problems to the examiner - self-limited or minor...
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    Ecode 917.2

    I agree with those codes just wondering if I didn't need to show something about the patient being in the water when he struck the rock; hence, the E917.2. Maybe the E002.0 is sufficient enough for that. Thanks.
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    Ecode 917.2

    Auditing a record where pt came to the ED for a laceration to 3rd toe that he sustained while swimming in a lake and stepped on a sharp rock. I am thinking the Ecode should be E917.2, striking against or struck accidentally in running water; but I am thrown by "running water". Does anyone...
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    Dx & Mgmt Options-sleep study results

    Est pt is seen in clinic for review of sleep study results. I am having a hard time with where this would fall under Dx&Mgt Options. Est problem, stable? The patient is not presenting with anything acute, worsening, or requiring add'l workup. :confused:
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    Is the Plan same as an order

    :confused:I am auditing some clinics records and under the Plan of Care the provider indicated "Testosterone 100mg q2w". We are having a difference of opinion if this is considered the order or does there need to be a separate order form filled out. The patient has been coming every two weeks...
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    Code for healed burns

    Thank you very much! Very helpful.
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    Code for healed burns

    I am auditing some records in a burn clinic and struggling with the dx code assignment for patients who come in for a recheck and their burns are healed and they are released from treatment. Since the burn is healed the acute code would not be assigned. Is a V-code appropriate? Aftercare? My...
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    DX Dilated Earlobe Piercing

    Yes, I guess I should have been a little more clear. No compications such as infection, etc. Patient had large ear piercing and wants the holes closed now.
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    DX Dilated Earlobe Piercing

    I am stumped on a diagnosis code for "dilated earlobe piercing. Patient is to RTC for repair. thanks!
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    Does anyone really understand the application of External Cause E-Codes?

    I am still trying to get a grasp on the External status codes and found this post. Very helpful but I am still confused on a scenerio that happens at home. Patient tripped and fell on a hose at home and cut his lip. Is there any External status code that would be assigned? Most of the time...