ICD-10 Coding Snapshot
CC: Fall and laceration.
HPI: Julia is a 42-year-old woman who was running to catch a taxi when she stumbled, fell, and struck her face on the sidewalk. She had taken the day off of work and was shopping downtown. She denies loss of consciousness but says she was dazed for a few seconds after it happened. She complains of pain over the chin and right forehead where she has lacerations. She denies neck pain, back pain, extremity pain, or pain in the abdomen.
PMH: Negative. MEDS: None. ROS: As above. Otherwise negative.
PHYSICAL EXAM: This is a woman in no apparent distress.
Vital Signs: BP 165/95, HR 80, RR 12, Temp 98.4, SpO2 95%.
HEENT: No palpable step offs. There is blood over the right eyebrow area where there is a small 1 cm laceration and surrounding abrasion. Also, 2 cm laceration over the base of the chin without communication to the oro-pharynx. No other trauma noted. No septal hematoma. No other facial bony tenderness.
Chest: Breathing comfortably; equal breath sounds.
Heart: Regular rhythm.
Ext: No tenderness or deformity; pulses are equal throughout; good cap refill
Neuro: Awake and alert; moves all extremities; cranial nerves normal.
COURSE IN THE ED: Patient arrived and was placed on monitors. An IV had been placed in the field and labs were drawn. The lacerations were explored and debris was removed from the eyebrow laceration. Both lacerations were irrigated and closed with simple interrupted sutures. Labs showed normal CBC, Chem-7, and U/A except there was moderate protein in the urine. Patient was released and instructed to see her family physician for follow-up care of the lacerations.
S01.121A Laceration with foreign body of right eyelid and periocular area, initial encounter
S01.81XA Laceration without foreign body of other part of head, initial encounter
W01.0XXA Falling from same level from slipping, tripping, or stumbling without subsequent striking against object, initial encounter
Y93.02 Activity, running
Y92.480 Sidewalk as the place of occurrence of the external cause
Y99.8 Other external cause status
Rationale: In ICD-10-CM, when a patient presents with an injury, the injuries and the external cause should be coded. The codes for the injuries will contain encounter information to indicate the treatment status of the patient (initial/subsequent encounter, sequela). In this case, the patient is presenting with fresh injuries, making this an initial encounter.
Wounds in ICD-10-CM can be identified by codes that are more specific than “wound, open, by site.” The physician states these are lacerations, and that is how they are coded in ICD-10-CM. One has a foreign body and the other does not, which is also shown in the codes chosen.
The external cause codes are added because this is the first time the patient is presenting with the injury. The documentation includes how the patient was injured (fall), what the patient was doing (running), where the patient was (sidewalk), and their status (not working).
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