Emergency department external cause coding

In this Emergency department external cause coding training  of a patient for a injury how the incident has happened i.e nothing but external cause coding is explained clearly.

                                            Head injury chart

Patient name: ABC ,Age :25                                                                                            Date of service :1/2/2018

MRN number: 123456                                                                                                     Physician name: xyz

Chief complaint: Head injury

Hpi:

Patient is coming with head injury which is painful while walking patient has fallen down from steps hitting the head this happened at home around 3 o Clock in the morning patient denies any other complaint.

PMH:

Personal history : None

Family history : Mother is diabetic

Social history : None

ROS(Review of system):

Constitutional Symptoms: weight : 52

HEENT: Head swelling

Respiratory: Normal

Gastrointestinal: Normal

Genitourinary: Normal

Musculoskeletal: Normal

Neurological: Normal.

Physical Examination:

Constitutional Symptoms: weight : 52

HEENT: contusion of head other than that everything is normal.

Respiratory: Normal

Gastrointestinal: Normal

Genitourinary: Normal

Musculoskeletal: Normal

Neurological: Normal.

  • Workup done :
  • Ct head
  • Findings : swelling is observed in frontal part of head. No intracranial hemorrhage is observered.

Medical decision making:

Patient is coming with head injury physician has Ordered CT head in order to find out any hemorrhage.Negative ct findings except for swelling of head.  Injury is cleaned and treated

Final impression:

  1. Head contusion.
  2. Fall from stairs.

Old records reviewed

Md physician sign:  xyz

 

  • ICDS:
  • Admission diagnosis: s09.90xa
  • Principal diagnosis:
  • s00.93xa-Head injury,
  • w10.9xxa-fall from stairs,
  • y93.01-walking, (actvity)
  • y92.009-Place of ocurrence home
  • CPTS: 99284-25

 

Icd-10 coding with external cause coding audio and video

Cpt coding audio and video

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