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Looking for an injury code..... please help

  1. #1
    Default Looking for an injury code..... please help
    Medical Coding Books
    My doctor coded out the below note (thru our EMR) with the E code E885.9. I need the 800/900 code to bill with this. I am thinking about using 850.5, but I wanted to get feedback from my fellow coders. Please help ... Thanks




    He was dragging some limbs in the yard and tripped and fell and struck his head on the corner of the shed. He cut his head and was uncounsciouness for a period of time. He went to SHH. He waited until several days later to go to the ER. He woke up and felt fine without a bad headache, but did see he had cut his head and bled. Later he thought he would not know if he had internal damage so he went to the UCC 4 days later after thinking about it. He was concerned to have someone look at it to make sure the wound wasn't getting infected. He was sent to the ER. He had a CT of the brain in the ER. The CT showed some changes of strokes. He has a history of high cholesterol. He is on Altoprev and Zetia. He is intolerable to statins. He sees a lipid specialist in Mobile, Alabama. He is not taking the fish oil and we discussed he needs to get back on it. He is frightened about having a stroke because his family history with his mom having a stroke. We talked about the results of his CT scan may be old changes, even as old as from birth, and there is no way to tell how old it is because we have no previous brain CT to compare it to. He is encouraged to try to stay healthy and not focus on the CT results. He doesn't smoke, he quit several years ago.

    Current Problems:
    Chronic low back pain
    Contracture of palmar fascia
    Essential hypertension
    Hypercholesterolemia
    Leg weakness

    Allergies:
    Penicillins:
    Tetracyclines:
    Phenobarbital:
    Astelin:

    Current Medications:
    Altoprev 60mg Tablets, Extended Release Take 1 tablet(s) by mouth each evening
    Astelin 137mcg/1spray Nasal Spray 2 spray(s) in each nostril bid
    Cyclobenzaprine HCl 10mg Tablet one tablet tid
    Fluticasone Propionate 50mcg Nasal Spray 1 spray(s) each nostril bid
    Nexium 40mg Capsules, Delayed Release Take 1 capsule(s) by mouth daily
    Zetia 10mg Tablet Take 1 tablet(s) by mouth daily

    OBJECTIVE:

    Vitals:

    Current: 9/2/2009 9:18:50 AM
    Ht: 69.5 inches; Wt: 200 lbs; BMI: 29.11
    T: 97.9 F (oral); BP: 137/83 mm Hg (left arm, sitting); P: 83 bpm (left arm (BP Cuff), sitting); R: 17 bpm

    Exams:
    PHYSICAL EXAM:
    GENERAL: well developed, well nourished; well groomed;
    E/N/T: EARS: external auditory canal normal; bilateral TMs are normal; OROPHARYNX: oral mucosa is normal; normal palate; normal tongue; posterior pharynx shows post nasal drainage, cobblestoning, and erythema of posterior pharynx;
    RESPIRATORY: normal respiratory rate and pattern with no distress; normal breath sounds with no rales, rhonchi, wheezes or rubs;
    CARDIOVASCULAR: normal rate; rhythm is regular; normal S1; normal S2; no cyanosis; no edema;
    SKIN: curved long healing laceration posterior scalp on the right side, it is about 5 to 6 inches long;
    NEUROLOGIC: mental status: alert; cranial nerves II-XII grossly intact;
    PSYCHIATRIC: appropriate affect and demeanor;

    ASSESSMENT:

    E885.9 Fall from other slipping, tripping, or stumbling
    434.91 Cerebral lacunar infarct
    272.0 Hypercholesterolemia
    401.1 Essential hypertension

    PLAN:

    Hypercholesterolemia
    Continue current medications,

    Essential hypertension
    Continue current medications,


    CHARGE CAPTURE:

    Primary Diagnosis:
    E885.9 Fall from other slipping, tripping, or stumbling

    Orders:
    99214 Office/outpatient visit; established patient, level 4

    434.91 Cerebral lacunar infarct

    272.0 Hypercholesterolemia

    401.1 Essential hypertension
    Sincerely,

    Kristie Stokes, CPC, CPMA, CCS, CMDP, ICDCT-CM

    AAPCCA Board of Directors 2014-2017
    Region 1 - Northeast
    Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, New York

    Today, give a stranger one of your smiles. It might be the only sunshine they see all day.

  2. #2
    Location
    San Antonio, Tx
    Posts
    73
    Default
    First of all, E-codes are not to be used as "primary" codes. They are only to be used as additional and/or detailed analysis of an injury, poisoning or other adverse effects. Secondly, what did your Dr. see this pt for? Was this just a follow-up from the ER? If he was seen for an ER F/U, then you would need to look at the ER notes in order to get a better picture of the DXs. If he is not seeing your Dr. for an ER F/U, then is he being seen for:
    1) leg weakness 780.79
    2) Hypercholesterolemia 272.0
    3) Chronic low back pain 724.2, 338.29

    It appears that he is being seen for ER F/U. In which case I would code:
    1) Laceration to the head 873.8 E888.1
    2) leg weakness 780.79
    3) RX Refill V68.1

    As for the CT, your Dr. does not seem to be as concerned as the pt with it's results. I'm not so sure about picking up the Infarcts. Anyone have any input for this? I am ok with the Level of E&M based on your info from the EMR.
    I hope this helps.

    Ray
    Ray Galvez CPC

  3. #3
    Default
    Yes it is a ER follow up and I know that you can't use the E code as the primary, that's why I was looking for the correct injury code to apply. Thank you for your input, I will check out the code you suggested.

    Thanks
    Sincerely,

    Kristie Stokes, CPC, CPMA, CCS, CMDP, ICDCT-CM

    AAPCCA Board of Directors 2014-2017
    Region 1 - Northeast
    Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, New York

    Today, give a stranger one of your smiles. It might be the only sunshine they see all day.

  4. #4
    Location
    Columbia, MO
    Posts
    12,531
    Default
    You would not code a laceration as the ER encounter was serveral days prior to your physician seeing the patient. The infarct as I understand from the note is old and he is seeing evidence of this on the CT but it is not in an acute state. So I would tend to go with a V71.x for obsevation and evaluation of other accident with nothing found. This is a first listed only code.

    Debra A. Mitchell, MSPH, CPC-H

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