Question

CHAPTER 8: MUSCULOSKELETAL SYSTEM

Case 8-1

Assign an external cause code to indicate how the injury occurred.

LOCATION: Inpatient, Hospital

PATIENT: Tara Barron

ATTENDING PHYSICIAN: Gary Sanchez, MD

SURGEON: Gary Sanchez, MD

PREOPERATIVE DIAGNOSIS: Stab wound, right upper abdominal quadrant.

POSTOPERATIVE DIAGNOSIS: Same as Preoperative.

PROCEDURE PERFORMED: Exploration of stab wound, right upper quadrant of abdomen, with closure of fascial defect.

ANESTHESIA: General.

PROCEDURE: The patient was brought to the operating room and placed under general anesthesia; we then removed the jar lid from around the knife as well as the patient’s clothing, and prepped with Betadine solution. We extended the incision on either side of the right upper quadrant stab wound 2-3 cm and carried the dissection through subcutaneous tissues using electrocautery. We followed the knife down along its tract and then could see the knife had penetrated the anterior sheath and the rectus fascia by about a quarter inch. We removed the knife and could see the tip was just within the rectus muscle. There was no peritoneal penetration. We then closed the fascia with interrupted 0 Vicryl and closed the skin with vertical mattress 3–0 Ethilon sutures.

All sponge and needle counts were correct. Patient tolerated this well and was taken to recovery in stable condition.

1. What is the main term and the subterm in the CPT referenced for this procedure?  
2. What is the name, in main term and sub term of the diagnosis?
3. What is the service code(s):

4. What is the ICD-10-CM Code(s):

5. Can the repair be reported separately?
6. How far had the knife penetrated?

Answer 1

1) Wound exploration is defined as exploring the wound for any infection or presence of foreign body. The main term in this scenario is " Exploration of stab wound " The sub term in CPT is " location : right upper quadrant of abdomen .

2) Diagnosis is defined as identifying the diseases and illness based on thorough examination, laboratory studies , invasive and noninvasive diagnostics tests . The name in main term is " Stab wound " sub term is " right upper abdominal quadrant"

3) Service code in medical coding is defined as the procedure performed by the qualified physician, nurses or qualified health care professionals. The service done in this scenario is Exploration of stab wound , right upper quadrant of abdomen with closure of fascial defect. Current procedural terminology code for this service is 20102 ( Exploration of stab wound , right upper abdominal quadrant)

4) International classification of disease is used to categorize all diseases and symptoms based on codes. S31.140A codes is ICD 10 code for the diagnosis Stab wound right upper quadrant of abdomen with penetration of foreign body ( knife).

5) Repair codes are inclusive of global surgical period so it is not codes separately .

6) Knife has been penetrated quarter inch into the anterior sheath and rectus fascia.