Question need help coding

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21
Location
Portland , OR
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0
I was thinking for coding 10140 but was not sure .


Chief Complaint: L 1st toe/toenail pain

History of Present Illness: Dropped heavy ramp on L 1st toe yesterday, since has had throbbing pain with bleeding under toenail. No bruising, no swelling of toe

Review of Systems:
Cardiovascular:

Denies Dyspnea on Exertion and Edema
General:
Admits Able to Conduct Usual Activities and Comfortable
Denies Apparent Distress and Change in Strength
Musculoskeletal:
Admits Myalgia and Bruising under nail bed L 1st toe .
Denies Decreased Range of Motion , Joint Pain and Swelling
Neurological:
Denies Numbness and Paresthesia
Respiratory:
Denies Dyspnea
Skin:
Admits New Lesions

Vital Signs:
Temp 96.40 F, Pulse 71 b/m , Respiration 16 b/m, BP 130/80 mm/Hg SAO2 98% Taken on Jan 16, 2020 at 10:03 AM by Miss Porter, Melissa

Allergies:
Codeine (Drug)

Current Medications:
Patient currently takes no medication
Past Medications:
Cefdinir 300 MG Oral Capsule: 1 Capsule(s) every 12 hours , Start 10/31/2019, Qty 20 Capsule(s) For 10 Day(s), - Auto Completed on 01/16/2020
Neomycin-Polymyxin-HC 3.5-10000-1 Otic Suspension: 3 drops in affected ear TID x 7 days., Start 10/31/2019, Qty 10 Milliliters For 7 Day(s), - Auto Completed on 01/16/2020
Amoxicillin 500 MG Oral Tablet: 1 Tablet(s) every 12 hours , Start 10/26/2019, Qty 20 Tablet(s) For 10 Day(s), - Auto Completed on 01/16/2020

Physical Exam:
Constitutional

Appearance: No distress, Alert and oriented x 3
Respiratory
Respiratory Effort: No acessory muscle use no distress
Cardiovascular

circ intact distally L 1st toe
Musculoskeletal

TTP to l distal 1st toe, subungual hematoma, but no other swelling/bruising, FRoM 1st toe, mild pain with movement.
Skin and Subcutaneous Tissue

Subungual hematoma L 1st toenail
Neurologic

limping gait
Psychiatric
Judgment and Insight: Appears appropriate; Mood and Affect: Affect appropriate

XR L 1st toe = No Fx, normal alignment, no STS

Assessment And Plan:
1) L 1st toe subungual hematoma - 2 burr holes made with 18g needle, small about of serosanguinous fluid expressed, suspect this blood has coagulated. Pt had some relief after drainaged. Advised warm soaks.

Diagnoses:
Subungual hematoma - L60.8
 

wisibyusha

Networker
Messages
47
Location
Cordova, TN
Best answers
0
I believe S90.112A is more specific code for subungual hematoma and since this is the result of external injury, you might need to code hit by "heavy ramp" as external cause. For the procedure, the CPT code 11740 is more appropriate based on the procedure done. Hope this helps.
 
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