Wiki Code A Round-Family Practice-help!

mandyfelton

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Hi,

I'm working on a Code A Round-Family Practice-Round 1-Note 2 and I am having such a hard time coming up with the ICD-9 code(s) for the senario. Can someone guide me in the right code range, there could be more than one ICD-9 code but I don't think so. I'm not asking for the answer. Any help is much appreciated.

Mandy :)

CHIEF COMPLAINT: Mouth injury.
HISTORY OF PRESENT ILLNESS: Joshua, age 11 months, here with mother is being seen on an emergent basis. One hour ago, he fell on a baby walker. Mother noticed a lot of bleeding from the mouth and called and was told to come right in. No loss of consciousness or other injury noted.
ALLERGIES: None known.
MEDICATIONS: None.
EXAMINATION: GENERAL APPEARANCE: Looks well, alert and responsive. Weight: 22 pounds 6 ounces. T: 98.1F. SKIN: Swelling of the upper lip, especially on the left side. Laceration of frenulum with small amount of acute bleeding. HEENT: Teeth do not feel loose. No tenderness to palpation.
IMPRESSION: Laceration of frenulum.
PLAN: Reassured mother that this does not need any special treatment. Recommended soft bland diet for few days while it heals. Recheck p.r.n.
 
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