LOCATION: Hospital Emergency Department PATIENT: Brad Nelson SURGEON: Paul Sutto
ID: 122008 • Letter: L
Question
LOCATION: Hospital Emergency Department
PATIENT: Brad Nelson
SURGEON: Paul Sutton,
MD PREOPERATIVE DIAGNOSIS: Complex eyebrow laceration, 2.8 cm.
POSTOPERATIVEDIAGNOSIS: Complexeyebrowlaceration,2.8cm.
PROCEDURE PERFORMED: Cleaning and suturing of laceration. ANESTHESIA: 1% Lidocaine with epinephrine.
INDICATIONS FOR PROCEDURE: The patient is a 12-year-old male who fell off a four-wheeler while driving it. The patient sustained a complex eyebrow laceration, and he is now undergoing repair.
PROCEDURE: The area was anesthetized with 1% Lidocaine with epinephrine. We then irrigated the area thoroughly. The wound was then scrubbed with Betadine. The entire skin area was prepped with the same Betadine solution. Sterile dressings were placed around the wound. The wound was then closed in 2 layers, the first layer with interrupted 4-0 Vicryl suture. The skin was then closed with 5-0 interrupted nylon suture in the area of the eyebrow. The rest of the incision in both directions was closed with interrupted 6-0 nylon suture. This was a complex laceration. The wound was then covered with Bacitracin. The patient was then discharged home with a prescription for Keflex. He has had a recent tetanus shot, so this will not be necessary. He is instructed to follow up in 1 week to have the sutures removed.
One or more of the following codes are reported incorrectly for this case.
Indicate the incorrect code or codes. SERVICE CODE(S): Complex repair, 13152 ICD-10-CM DX CODE(S): Periocular laceration, S01.119
INCORRECT/MISSING CODE(S):
Explanation / Answer
Incorrect/ Missing Code: S01.119
Correct code: S01.119A- Periocular laceration without foriegn body- Initial encounter
As this is the case of initial encounter for traetment, 'A' should be used along with the cose for laceration.
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