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:
- Head contusion.
- 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
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https://www.udemy.com/course/icd-10-guidelines-for-medical-coding-with-scenarios/?referralCode=C480617856FBC7B9E2CC
Icd-10 coding with external cause coding audio and video
Cpt coding audio and video
