Our first patient, nine-year-old Chris, arrived with a really nasty case of chicken pox. Dr. Killdare doesn’t document whether Chris suffered any complications with his chickenpox, so we need to query. Chris could suffer from encephalitis, myelitis, or encephalomyelitis along with his chickenpox (B01.1-) or he could have other complications (B01.8-). Fortunately for Chris, he avoided complications, so we would report code B01.9 (varicella without complication).
If you don’t know varicella is the official name of chickenpox, don’t worry. In the ICD-10-CM alphabetic index, under chickenpox, it says, see varicella.
Our next patient, Nancy, is back for a follow up visit with Dr. Killdare after fracturing her right ulna. When we look up her initial injury, we find that Dr. Killdare treated Nancy for a displaced fracture of olecranon process without intraarticular extension of right ulna (S52.021A) last month. In his documentation for today’s visit, Dr. Killdare notes Nancy’s fracture is not healing correctly.
So we still need to know whether it’s delayed healing, nonunion, or malunion. By reading further in Dr. Killdare’s note, we find documentation of malunion, so we would report S52.021P. That’s almost the exact same code we reported during Nancy’s initial visit. The only difference is the seventh character. For her first visit we used ‘A’ for initial, while this visit, we used ‘P’ for malunion.
If Dr. Killdare documented delayed healing, we would use ‘G’ for the seventh character. For a nonunion, we would use ‘K’ as the seventh character extension. Keep in mind the majority of the code—those first six characters—don’t change. Anytime Nancy comes in for treatment of that same fracture, we would code S52.021 with the appropriate seventh character.
Bill, an unlucky cave explorer, rounds out our Monday at Fix ‘Em Up.
A falling rock hit Bill in the back during a cave-in, leaving some nasty bruises. Bill also scrapped both palms. Dr. Killdare documented this as the first encounter. What should we report?
Let’s start with the bruised back. Where specifically are the bruises—shoulder, neck, lower back, or multiple sites? In his notes, Dr. Killdare documents multiple lower back contusions, which leads us to S30.0xxA (contusion of lower back and pelvis).
Moving on, we next look at Bill’s scrapped palms. Are they lacerated, bruised, abraded, or all of the above? Also, did Bill injure any of his fingers? In his notes, Dr. Killare specifies a lacerated right palm with rocks in the cut, code S61.421A, (laceration with foreign body of right hand) and abrasions to the left hand, code S60.512A (abrasion of left hand).
Dr. Killdare also documents that he found a tiny piece of rock in the cornea of Bill’s right eye, so we would add code T15.01xA (foreign body in cornea, right eye).
Don’t forget to add W20.0xxA (struck by falling object in cave-in).
That’s all for Monday at Fix ‘Em Up. Remember to watch out for those falling rocks!