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:ELYSE OFFICE
RECORD NUMBER:00-15-83
DATE OF SERVICE:08-08-XX
PHYSICIAN:DR. KIM. M. D.
SUBJECTIVE: This 27-year-old female presents to the emergency room with a small lacerationto her right index finger.The patient works in central supply. She cut her digit on a clean razor blade. The patient notes that she is current on her tetanus immunization.
OBJECTIVE: Physical exam reveals a well-developed, well-nourished female. She is alert and oriented and in no acute distress. Vital signs are normal. Exam of her right index finger reveals a small 1 cm laceration to the volar fat pad.
TREATMENT: The wound was cleaned and injected with 1% plain Xylocaine. It was then sutures with three interrupted 5-0 Nylon sutures. Neosporin ointment and a sterile dressing were placed over the wound.
ASSESSMENT: Laceration, right index finger, sutured.
PLAN: Wound care instructions include keeping the wound clean and dressed with Neosporinointment. Sutures are to be removed in approximately 10days. She is cautioned to watch for any signs ofinfection.
ICD-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
APC: _____________________
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