What is the CPT E/M code? And what are the ICD-10-CM Diagnosis 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.
ICD -10-CM code is the tenth version of international classification of disease and is used by the healthcare workers to code a disease and is also used by the insurance company's for reimbursement purpose.
ICD -10-CM code for left ankle injury is S99.912A
CPT code is the current procedural terminology used by the healthcare workers to code a procedure and is also used by the insurance company's for reimbursement purpose.
CPT code for leg post mild splint is 29515
What is the CPT E/M code? And what are the ICD-10-CM Diagnosis codes? HPI: Patient is...
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...
What is the rationale for this case? what is the rationale for the secondary diagnosis codes? HPI: 4 Yrs 4 Mos male with pmh sig for chronic constipation who presents with 10 days of abdominal pain. Seen by PMD and diagnosed with viral etiology. Abdominal pain continued to come and go and was seen at Westside Hospital ED and given zofran, miralax-8 grams only given once. and discharged home. Seen 1 day PTA in ED at Mary Children’s Hospital and...
What is the rationale for this case? What is the rationale for the ICD-10- codes for this case? HPI: 9 Yrs 2 Mos female established patient who presents to the office with compliants of throat pain and neck pain since yesterday afternoon. Better with motrin (12.5ml, last dose at 0630 this morning). Worse with sitting down or laying down. No abdominal pain. Has slight headache at base of head. No new rashes (follows with dermatology for eczema, given a cream...
What is the professional code and the cpt ICD-10-cm codes for this case? HPI: The patient is an 11-year-old child who was admitted for abdominal pain. Today I am completing the initial H & P. He was sent over from his primary care physician’s office because of this pain. Mom states that the pain started today at about 1400 in the afternoon when it just suddenly hit him. He started to bend over and writhe in pain. It seems to...
What is the rationale for this case? what is the rationale for the secondary diagnosis codes? HPI: 4 Yrs 4 Mos male with pmh sig for chronic constipation who presents with 10 days of abdominal pain. Seen by PMD and diagnosed with viral etiology. Abdominal pain continued to come and go and was seen at Westside Hospital ED and given zofran, miralax-8 grams only given once. and discharged home. Seen 1 day PTA in ED at Mary Children’s Hospital and...
What is the professiona code and cpt icd-10-cm codes for this case? Reason for Visit: General history and physical, yearly exam, seen a year ago by me. HPI: Harry is here today for a general history and physical. He reports that he is currently feeling well and has no major concerns today. Chronic Medical Problems: Positive history of hypertension. Currently takes hydrochlorothiazide 25 mg 1 by mouth daily for this. He reports no headache, no visual changes, no chest pain,...
What is the professional code and the cpt icd-10-cm code for this case? Admitting Diagnosis: Suicide attempt. Inpatient Consult requested by Internal Medicine Provider, Dr. Smith. HPI: The patient is a 17-year-old girl with Salicylate overdose as a suicide attempt. She has a three-year history of depression, suicide attempts and self-mutilating behavior. She had a determined suicide attempt last night at about 1900 by an overdose of aspirin. She has been depressed chronically and has had over 10 suicide attempts,...
Q: Need help to Code ICD-10 CM for the diagnoses (primary & secondary) and all the CPT code for the procedure for following outpatient surgery case with explanation ORTHOPAEDICS HISTORY AND PHYSICAL DATE OF CONSULT: 11/8/2013 PRIMARY CARE PHYSICIAN: Jody L. Mathie, M.D. CHIEF COMPLAINT: Retained hardware left femur HISTORY OF PRESENT ILLNESS: is a 9 year old accompanied by his parents for history and physical examination. has a history of left femur fracture treated with closed reduction, flexible IM...
The Emergency Department Chair has asked for an audit of ED records in preparation for an upcoming Joint Commission survey. Your staff conducted the audit against the Joint Commission standard that addresses ED documentation. The results were very poor, with no consistency in documenting the required components. You check the medical staff by-laws and realize that there are no specifics related to ED documentation. Determine the Joint Commission documentation requirements for Emergency Department reports. List them here. Audit the five...
Code the following reports utilizing CPT codes, ICD-10-CM codes, and apply any applicable modifiers. Assignment #1 Description: The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy. GROSS DESCRIPTION: A. Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an 8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line. There is a 0.8 x...