Documentation Dissection - AAPC

[Pages:1]Documentation Dissection

Emergency Department Visit

HPI: The patient presents to the ED with right wrist pain |1|. Just prior to arrival, the patient fell |2| at home |3| and has had a constant moderate pain and swelling since the fall. Exacerbation factors consist of movement palpation. The patient's dominant hand is the right hand. The patient stepped on a lid on the floor, falling onto outstretched right hand |4|. She complains of right wrist pain. She is not anticoagulated, did not striker her head, and denies other complaint or injury.

Radiology Results: Minimally displaced fracture involving the distal radial meta-epiphysis |5| extending to the lateral margin of the articular surface for nondisplaced ulnar styloid fracture |6|.

Impression and Plan Closed fracture of the wrist

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|1| The right wrist is injured.

|2| Injury is the result of a fall.

|3| The injury occurred at home.

|4| Injury details.

|5| The patient has a displaced fracture of the distal radial meta-epiphysis.

|6| The patient also has a nondisplaced ulnar styloid fracture.

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What ICD-10-CM code(s) is/are reported?

ICD-10-CM Codes: S52.591A, S52.614A, W18.31XA, Y92.009

Rationale: The patient has a closed fracture of the right wrist. When looking at the radiology results, it is a displaced fracture of the distal radial meta-epiphysis and a nondisplaced fracture of the ulnar styloid. Look in the ICD-10-CM Alphabetic Index for Fracture, traumatic/radius/distal end and you are directed to see Fracture, radius, lower end. Look for Fracture, traumatic/radius/ lower end/specified NEC referring you to S52.59-. In the Tabular List, sixth character 1 is reported to indicate the right wrist and seventh character A is reported to indicate the initial encounter of a closed fracture. Look in the Alphabetic Index for Fracture/ ulna/lower end/styloid process/nondisplaced S52.61-. In the Tabular List, sixth character 4 is reported to indicate the nondisplaced right wrist and seventh character A is reported to indicate the initial encounter of a closed fracture. Seventh character extenders for traumatic fractures are discussed in ICD-10-CM Guidelines Section I.C.19.c.1. According to ICD-10-CM Guidelines Section I.C.20.a.2., external cause codes should be reported for the life of the injury. To locate the external cause code, look in the External Cause of Injuries Index for Fall, falling (accidental)/on same level/due to/stepping on an object W18.31-. In the Tabular List, W18.31 requires a seventh character. The code is only five characters long so a dummy placeholder X is placed in the sixth character position. Seventh character A is appended to indicate the initial encounter. According to ICD-10-CM Guidelines Section I.C.20.b, c, and k, a Place of Occurrence Code, Activity Code, and Activity Status Code should only be reported once on the initial encounter. This is the initial encounter (ED visit). The injury occurred at the patient's home. Look in the Index to External Cause of Injuries for Place of occurrence/home and you are directed to see Place of occurrence, residence. Place of occurrence/residence/ home Y92.009. The Tabular List confirms Y92.009 is reported for Home. The activity of the patient at the time of the injury and the activity status at the time of the injury are not known so these cannot be reported.

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