Code the following cases for outpatient facility purposes using ICD-9-CM, ICD-10-CM, and CPT codes. Sequence codes in the correct order.
Calculate the APC.
Assign modifiers when appropriate.
Use external cause codes when appropriate.
Do NOT code procedures that are captured by the facility chargemaster.
EMERGENCY DEPARTMENT VISIT
PATIENT:TIMOTHY OFFICE
RECORD NUMBER:15-68-24
DATE OF SERVICE:04-26-XX
PHYSICIAN:DR. KIM. M. D.
IDENTIFICATION: This is a 5-year-old Caucasian male.
CHIEF COMPLAINT: Skull laceration.
HISTORY OF PRESENT ILLNESS: This evening at 4:00 pm, patient was on a ladder to a swimming pool at the family's single-family house. He was about 3½ feet off the ground, when he slipped and fell onto his back and head. Patient did not suffer any loss of consciousness and has been acting normally, though he has a cut over the back of his head and is quite anxious. Patient has not had any nausea or vomiting.
ALLERGIES: NONE. Immunizations up-to-date.
CURRENT MEDICATIONS: Ental and albuterol.
PREVIOUS ILLNESSES: Historyofasthma.
PHYSICAL EXAM: VITAL SIGNS: T 99.3°F, P 72, R 22.
GENERAL: Young, Caucasian child in no acute distress.
HEENT: Normocephalic.Eyeswereunremarkable. TMs, no hemotympanium noted, nobattlesign noted, no facial asymmetry noted. There was a 2.5 cm laceration over the occipital region of thepatient'sskull.Thiswas lightly obliquely oriented. This was all the way throughthe skin, but the galea appeared intact and there were no palpable stepoffs.
NEUROLOGICAL: Patient had grossly intact exam with normal grip bilaterally and normal knee jerks bilaterally and normal gait.Over the patient's back, there were two superficial abrasions medial to the right medial scapula border. The more superior abrasion was 23 cm in size. The more inferior abrasion was 45 cm in size.
IMPRESSION: Two-point-five centimeter occipital skull laceration superifical abrasions over the right back area
PLAN: The patient's scalplaceration wastreated with TAC topical anesthetic. Patient continued to have painsensation afterthis, therefore, after the wound was prepped the area was infiltrated with 1% Lidocainewithepi. The wound wassubsequently closedwith four interrupted 40 prolene sutures.After being inspected, no debris or gross contamination was noted. Wound instructions were given. The patient is to follow up in 7days to have the sutures removed.
ICD-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
APC: _____________________
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