Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s), if appropriate. Remember, check the chapter specific, sub-chapter specific, and category specific notations within the Tabular List.
Marlena Hendricks brought her 13-year-old son, Paul, into my office as a walk-in. Paul stated that he fell through a sliding glass door, while chasing his brother, and sustained three lacerations: left knee, right knee, and left hand.
After physical examination, Dr. Smyth determined that the wounds of both knees and left hand required debridement and suture repair using 1% lidocaine for topical anesthetic.
Left knee: 5.5 cm laceration involving deep subcutaneous tissue and fascia, repaired with layered closure. Some debridement was performed.
Right knee: 7.2 cm laceration repaired with a single-layer closure.
Left hand: 2.5 cm laceration of the dermis, repaired with simple closure.
Plan: Instructions for keeping bandages and area clean, and change of bandages provided to Mrs. Hendricks. Follow-up in 10 days for suture removal. Call office PRN any problems or complications.
Be sure to list the codes, one code per box, in the correct order, from top to bottom. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices.
Determine the most accurate procedure codes, using the CPT code set and modifier(s), if appropriate.
You may not need all of the spaces provided.
Doctors impression: wounds of both knees and left hand required debridement and suture repair using 1% lidocaine for topical anaesthetic.
Left knee: 5.5 cm laceration involving deep subcutaneous tissue and fascia, repaired with layered closure. Some debridement was performed.
12032 - Intermediate repair of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet) - 2.6 cm to 7.5 cm
The complexity of repair can be identified by these terms used in the description: layered closure, involving deep subcutaneous tissue, Some debridement was performed – these indicate an intermediate repair.
Right knee: 7.2 cm laceration repaired with a single-layer closure.
Complexity of repair: repaired with simple closure, 2.5 cm laceration of the dermis – Simple repair
12002: Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm
Left hand: 2.5 cm laceration of the dermis, repaired with simple closure.
Simple repair:
12001: Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less
Using the techniques described in this chapter carefully read through the case study and determine the...
Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Remember, check the chapter specific, sub-chapter specific and category specific notations within the Tabular list. Harris Teal, a 19-year-old male, reports to the hospital-based urgent care clinic for headache and wheezing. Following examination, he is discharged with an acute frontal sinus infection, recurrent, and exacerbated asthma due to environmental dust allergies. Be sure to...
Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Remember, check the chapter specific, sub-chapter specific and category specific notations within the Tabular list. Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Remember, check the chapter specific, sub-chapter specific and category specific notations within the...
Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Remember, check the chapter specific, sub-chapter specific and category specific notations within the Tabular list. Harris Teal, a 19-year-old male, reports to the hospital-based urgent care clinic for headache and wheezing. Following examination, he is discharged with an acute frontal sinus infection, recurrent, and exacerbated asthma due to environmental dust allergies. Be sure to...
Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Remember, check the chapter specific, sub-chapter specific and category specific notations within the Tabular list. Harris Teal, a 19-year-old male, reports to the hospital-based urgent care clinic for headache and wheezing. Following examination, he is discharged with an acute frontal sinus infection, recurrent, and exacerbated asthma due to environmental dust allergies. Be sure to...
Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Remember, check the chapter specific, sub-chapter specific and category specific notations within the Tabular list. Renay Griffith, a 25-year-old female, recently returned from working for the Red Cross overseas. She presents to the clinic for an evaluation of a rash. Dr. Leisom evaluates the patient and diagnoses her with cutaneous leishmaniasis related to her...
Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Remember, check the chapter specific, sub-chapter specific and category specific notations within the Tabular list. Roger Gill, a 39-year-old retired professional athlete, comes in with complaints of intermittent joint pain, particularly in his left shoulder. He was a pitcher on a AA league baseball team. He also states he feels tenderness at the outer...
Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Remember, check the chapter specific, sub-chapter specific and category specific notations within the Tabular list. Angel Dunbar, a 27-year-old male, presents to see his physician, Dr. Davison, with the complaints of difficulty breathing, muscle weakness, and fatigue. Following a complete examination, Dr. Davison notes ataxia and sudden muscle spasms in Angel’s legs. The lab...
Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s), if appropriate. Remember, check the chapter specific, sub-chapter specific, and category specific notations within the Tabular List. Nadiya Longstep was rescued from her apartment building, which was engulfed in a two-alarm fire. The firemen carried her out and she was handed over to the EMTs, who immediately began to examine the burns on 45% of her...
Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Remember, check the chapter specific, sub-chapter specific and category specific notations within the Tabular list. PATIENT: Noah Logan PREOPERATIVE DIAGNOSIS: Midface deficiency. POSTOPERATIVE DIAGNOSIS: Cleft hard palate with cleft soft palate OPERATIVE PROCEDURE: LeFort I osteotomy with advancement. ANESTHESIA: General via nasal intubation. BLOOD LOSS: 200. FLUIDS: 600. URINE OUTPUT: 125. DRAINS: No drains....
Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Remember, check the chapter specific, sub-chapter specific and category specific notations within the Tabular list. PATIENT: Noah Logan PREOPERATIVE DIAGNOSIS: Midface deficiency. POSTOPERATIVE DIAGNOSIS: Cleft hard palate with cleft soft palate OPERATIVE PROCEDURE: LeFort I osteotomy with advancement. ANESTHESIA: General via nasal intubation. BLOOD LOSS: 200. FLUIDS: 600. URINE OUTPUT: 125. DRAINS: No drains....