leannreichenberg
New
Following is the partial documentation I received for an EMD encounter:
Chief Complaint/Reason for Visit: GSW, 1 BB in left cheek lateral to nose, below left eye. Subjective: 46 yo male Fish and Wildlife
educator here to do class and mentored pheasant hunt as part of hunter safety class was shot by student with GS lead pellet that
entered his L cheek and (eventually was located near the insertion of the lev labii sup alaeque nasal muscle) although initially upon
palpation it was presumed embeded more proximally in the lev labii sup m due to palpable swelling upon patient's initial presentation
and the entry wound, below that point, near lev anguuli. The shooting occurred ~ 1430 accoriding to his colleague who accompnied
him
Impression and Plan:
Diagnosis: Lead pellet GSW accidentally aquired during teaching class. Impression: I G Rocephin IM
Rx Norco 1 every 4-6 h prn pain not releived by advil or aleve #20 in Rx and Nurse dispensed #four from floor stock until he could get
to a pharmacy given date and time of ER release.
Rx Bactrim DS one twice daily # 20 which should be started no later than in am.
Plan: Initially area was cleaned with hibiclens and betadine, and then anesthetized with total dose( over the entire 90 minites) of 5.3
cc of 2% xylocaine w/epi given in small increments as needed. He was steriled draped an initially a 1.5 cm incision with a 15 blade
was made over indurated area of cheek that I felt the projectile was likely to be. After probing, and extending the lac to 2.2 cm and still
not finding the object. I placed first one then a second sterile needele( one directly acros mid point of the incision horizontally and
another 2 cm proximal, immediately next to the edge of the nose going vertically). We then proceeded to take serieal facial views to
locate the projectile. Once the projectile was located, we went back to the projecture room, provided additional local and prep and
finally located the tiny pellet intact. There was no arterial bleeding. EBL, 3-5 cc. After removing pellet the wound was irrigated with NL
saine with flushe guad spray and then deeper angio cath( w/o needle repetatively for total of 120 cc. The would closure consisted of 3
deep interupted 4-0 vicryl sutures. And then the skin was closed with sterrin strips and tincture of bensoin. Light pressure dressing
followed by short term ice pack. Eye, nasal and ear exam performed again after repair. patient tolerated all of this very well.
I am wondering how others would code this. Would you use a code from 20100-20103 area (although none indicate face) along with an intermediate closure or would you use 10121 and the closure, or do you have other ideas. Thanks
Chief Complaint/Reason for Visit: GSW, 1 BB in left cheek lateral to nose, below left eye. Subjective: 46 yo male Fish and Wildlife
educator here to do class and mentored pheasant hunt as part of hunter safety class was shot by student with GS lead pellet that
entered his L cheek and (eventually was located near the insertion of the lev labii sup alaeque nasal muscle) although initially upon
palpation it was presumed embeded more proximally in the lev labii sup m due to palpable swelling upon patient's initial presentation
and the entry wound, below that point, near lev anguuli. The shooting occurred ~ 1430 accoriding to his colleague who accompnied
him
Impression and Plan:
Diagnosis: Lead pellet GSW accidentally aquired during teaching class. Impression: I G Rocephin IM
Rx Norco 1 every 4-6 h prn pain not releived by advil or aleve #20 in Rx and Nurse dispensed #four from floor stock until he could get
to a pharmacy given date and time of ER release.
Rx Bactrim DS one twice daily # 20 which should be started no later than in am.
Plan: Initially area was cleaned with hibiclens and betadine, and then anesthetized with total dose( over the entire 90 minites) of 5.3
cc of 2% xylocaine w/epi given in small increments as needed. He was steriled draped an initially a 1.5 cm incision with a 15 blade
was made over indurated area of cheek that I felt the projectile was likely to be. After probing, and extending the lac to 2.2 cm and still
not finding the object. I placed first one then a second sterile needele( one directly acros mid point of the incision horizontally and
another 2 cm proximal, immediately next to the edge of the nose going vertically). We then proceeded to take serieal facial views to
locate the projectile. Once the projectile was located, we went back to the projecture room, provided additional local and prep and
finally located the tiny pellet intact. There was no arterial bleeding. EBL, 3-5 cc. After removing pellet the wound was irrigated with NL
saine with flushe guad spray and then deeper angio cath( w/o needle repetatively for total of 120 cc. The would closure consisted of 3
deep interupted 4-0 vicryl sutures. And then the skin was closed with sterrin strips and tincture of bensoin. Light pressure dressing
followed by short term ice pack. Eye, nasal and ear exam performed again after repair. patient tolerated all of this very well.
I am wondering how others would code this. Would you use a code from 20100-20103 area (although none indicate face) along with an intermediate closure or would you use 10121 and the closure, or do you have other ideas. Thanks