Question

What is the rationale for this case?

What is the rationale for the ICD-10-CM secondary codes?

HPI: Patient is 6 Yrs male who presents to the ER with left ankle injury last night. Twisted his ankle while playing. No having pain and swelling of left lateral ankle. Able to ambulate but with a limp. No numbness or tingling. No other injuries.
Past Medical History: Past Medical History:
ENVIRONMENTAL ALLERGIES
Past Surgical History: No past surgical history on file.
Immunizations: Immunizations Up to Date: Yes
Allergies: No Known Allergies
Medications: The patient's current medications are listed in the medication portion of the chart.
Family History:
Cardiac/Sudden Death: negative
Diabetes: negative
Asthma: negative
Hematologic: negative
Genetic: negative
Social History:
Daycare or School:yes
Smokers:unknown
Review of Symptoms:
Constitutional: negative
Eyes: negative
ENT/Mouth: negative
CV: negative
Respiratory: negative
GI: negative
GU/Gyne: negative
Last menstrual period: not applicable
Musculoskeletal: HPI
Skin/Breast: negative

Neurologic: negative
Psychiatric/Developmental: negative
Endocrine: negative
Hematologic: negative
PHYSICAL EXAM:
Vitals:
BP:
98/54
Pulse:
112
Temp:
37 °C (98.6 °F)
Resp:
20
Weight:
43 kg
General Appearance: awake. Alert. Cooperative. No acute distress.
Pain: No
Head: Normal
Eyes: deferred
Ears: Deferred
Nose: Deferred
Throat: Deferred
Mouth/Teeth: moist mucus membranes.
Neck: deferred
Lungs/Chest: Deferred
Cardiac: Deferred
Abdomen: Deferred
Back: Deferred
Genitalia/GU: Deferred
Rectal: Deferred
Extremities: warm. Well perfused. Cap refill < 2sec.
Left lower extremity: no bruising. No erythema. Mild edema surrounding lateral malleolus with tenderness to palpation just anterior to the lateral malleolus. Full ROM of ankle with pain only with plantarflexion and eversion. Able to bear weight with mild limp
Skin: Normal
Evaluation and Management Case 003
3 | P a g e
Neurologic: Grossly Normal
Medical Decision Making
- XR ankle done to evaluate for fracture.
- XR ankle showed: "There is lateral soft tissue swelling and a small left ankle joint effusion. No definite fracture is identified. On the AP view, a very faint apparent curvilinear lucency is noted along the distal articular surface of the tibia. Although this raises the question of an osteochondral injury, it is not seen on the other views and such an injury would be quite unusual."
- The ortho resident on call reviewed the radiographs and recommended a short leg post mold splint and follow up in ortho clinic in 1 week.
- splint applied as described below.
- crutch teaching.
Splint Application Location: left ankle Splint applied for: ankle injury Circulation, sensation, and motor function was intact before and after splint application. A post-mold was applied using orthoglass splint. Post-splint application instructions were given to the patient/parent/guardian and understood.

Answer 1

# Rationale for this case is that it is a medical problem and medical services has to be provided to the patient as he has got injury in his left ankle while he was playing.

# Rationale for the ICD -10-CM CODE secondary codes are :-

- improve patient care quality and data reporting

- enhance claim processing

- promote interoperability across all industry stakeholders

Using ICD-10-CM code helps to :-

- Support value-based purchasing and Medicare’s anti-fraud and abuse activities by accurately defining services and providing specific diagnosis and treatment information;

- Support comprehensive reporting of quality data;

- Ensure more accurate payments for new procedures, fewer rejected claims, improved disease management, and harmonization of disease monitoring and reporting worldwide; and

- Allow the United States to compare its data with international data to track the incidence and spread of disease and treatment outcomes because the United States is one of the few developed countries not using ICD-10