Laceration Repair of Nail

LeaHarris

Networker
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Any ideas of how to code this? My provider is charging an E/M only but that doesn't seem correct.


*Laceration
- Was working in the trees pruning on the job. *
- He is self employed. *
- Chainsaw slipped and caught his Middle R finger. Went through his ring finger nail as well. *
- Happened about 11:30 this morning. *
- Bled pretty good for awhile. *
- Applied peroxide and a paper towel at the time. *
- Pain is manageable.

Review of Systems
Constitutional: Negative for fever, chills and malaise/fatigue.
Neurological: Positive for weakness (In R hand. ).


Past Medical History
No past medical history on file.
*

Current Outpatient Prescriptions*
Medication* Sig* Dispense* Refill*
•* lithium 300 mg capsule* Take 3 caps (total dose = 900mg) by mouth nightly at bedtime.* 90 Cap* 6*
**

No current facility-administered medications for this visit.*


*
Objective
**

Vitals

Filed Vitals:*
* 08/30/16 1425*
BP:* 135/83*
Pulse:* 70*
Temp:* 97.3 °F (36.3 °C)*
TempSrc:* Oral*
Resp:* 16*
Height:* 5' 9" (1.753 m)*
Weight:* 188 lb 9.6 oz (85.548 kg)*
SpO2:* 98%*


Estimated body mass index is 27.84 kg/(m^2) as calculated from the following:
* Height as of this encounter: 5' 9" (1.753 m).
* Weight as of this encounter: 188 lb 9.6 oz (85.548 kg).
Normalized BMI data available only for age 2 to 20 years.
**

BP Readings from Last 3 Encounters:*
08/30/16* 135/83*


Wt Readings from Last 3 Encounters:*
08/30/16* 188 lb 9.6 oz (85.548 kg)*

Physical Exam
Constitutional:
Healthy appearing, friendly, alert young male in NAD
HENT: *
Head: Atraumatic.
Eyes: EOM are normal.
Pulmonary/Chest: Effort normal.
Musculoskeletal:
Full ROM in right hand in all digits
Neurological:
Normal sensation in all digits
Skin:
Jagged, macerated laceration in area of dorsal area of DIP joint of 3rd digit, nail laceration to 4th


*
Assessment and Plan
*Paitient is a 26 year old male here with lacerated fingers. Tissue to macerated for repair. Laceration was anesthetized with 1% lidocaine w/o epi. Irrigated copiously with NS and explored. No signs of tendon or bony involvement. Cleaned and dressed with silvadene, topical antibiotics and pressure dressing. Nail was cleaned and dermabond was applied. Well tolerated. TdAP given. Return precautions given.
 
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Laceration repair of nail

If I am reading this note correctly, the physician explored, cleaned, and applied a pressure dressing to one wound and closed the other with a tissue adhesive (simple repair). Both the repair and E/M for the evaluation of extent of all injuries would be reportable services. This sounds like an encounter with considerable work and risk to the patient (e.g., nerve injury, infection). Would be a shame to leave a billable service unreported.

Hope that is helpful.
Cindy
 
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