Author Question: Patient was involved in an auto accident. He was the driver of a car that hit a pothole and he lost ... (Read 100 times)

karateprodigy · **on:** Jun 27, 2018

Patient was involved in an auto accident. He was the driver of a car that hit a pothole and he lost control of the car and hit a tree. The airbags deployed. He arrives at the ED on a backboard and has a cervical collar around his neck. He is complaining of neck pain with radiation down the right arm. His past medical history is significant for HTN, GERD, glaucoma, and right knee replacement. His blood pressure was slightly elevated on arrival at the ED and was closely monitored. Based on his physical symptoms, he had a CT of the head and neck, which were negative for bony injury. The physician decided to seek an ophthalmic consult because he wanted to make sure there was not any injury to eyes. Aside from the preexisting glaucoma, the eyes appeared to be uninjured. He was place in a neck brace, sent home with some muscle relaxants, and told to follow up with his PCP.

Diagnoses: Whiplash injury, cervical spine; HTN, GERD, glaucoma

First-listed/principal diagnosis: ________
Secondary diagnoses: ________
Procedures: ________

What will be an ideal response?

Question 2

When assigning a PCS code, the coder may select more than one value from some of the columns.

Indicate whether this statement is true or false.

Jbrasil · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

First-listed/principal diagnosis: ________
Answer: Whiplash injury S13.4XXA

Secondary diagnoses: ________
Answer: Driver of car that hit tree V47.02XA; HTN I10; GERD K21.9; H40.9

Procedures: ________
Answer: CT head and neck BW29ZZZ; Immobilization of neck 2W32X3Z

Answer to Question 2

FALSE