Question

This 17-year-old girl was a passenger on a motorcycle and was thrown from the back of the motorcycle. She sustained multiple contusions and reported pain in her left forearm and ribs. Patient was taken to x-ray to have the hand and ribs examined. While waiting for the results, the nurse cleaned an abrasion on her left knee, on her left cheek, and on the scalp. She had a 1.1-cm. laceration on her right palm which the physician examined. It was debrided to remove a significant amount of dirt, gravel, and even wood chips. It was then copiously washed with sterile water. The physician examined the palm and was able to suture it using single layer 3.0 chromic sutures.

X-ray results showed a non-displaced fracture of the distal one-third of the left ulna. The radius was not involved. A long-arm plaster cast was applied to the arm. There were no injuries sustained to the ribs. There appears a large ecchymosis to the right upper quadrant but there is no flank tenderness or swelling of the organs.

The patient is given a prescription for Lortab l q. 6 hrs. p.r.n. and told to see her family physician in the morning.

What codes are reported for this emergency department visit exclusive of the evaluation and management codes and ancillary procedure codes assigned by the chargemaster?

ICD-10-CM Code(s):

CPT Code(s):

Rationale for codes:

Answer 1

ICD-10-CM code(S): V29.10XA, S52.601A

CPT Code: 25530

Rationale: The patient had come to the emergency due to a motor vehicle accident. She is not a driver and she is a passenger and the incident of an accident is not specified. So the cause of an injury is coded as V29.10XA. During the accident, the patient had met with an ulnar fracture which is treated with a plaster cast. So the ICD code of S52.601A and CPT code of 25530 is used.