Directions:
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:JOSHUA OFFICE
RECORD NUMBER:00-15-90
DATE OF SERVICE:09-09-XX
PHYSICIAN:DR. KIM. M. D.
S: The patient comes in complaining of having a large bruise from his mid-upper arm down. He says that he bumps it occasionally on the skid loader and it is quite swollen and tender.It is swollen enough that it is causing a little bit of discomfort. There has been no injury except as described above. The patient is on Coumadin for blood clots that he has had in the past.
O: LUNGS: Clear. HEART:Regular rate and rhythm. Unremarkable
EXTREMlTTES: There is a large purple ecchymosis from the mid-biceps down to the hand. Distal neurovascular checks in the hand are normal.
LABORATORY/DIAGNOSTIC: Blood work shows a protime of37.1 with an INR of 7.5.
A: Hyperanticoagulalion with contusion of left arm.
P: We gave him twoampuls ofvitamin K. We will have him stop his Coumadin for 2 days and then he will start back at2.5 mg every other day. He isto have his blood checked in l week and follow up.
ICD-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
APC: _____________________
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