The patient was seen in the orthopedic clinic today for an urgent level 3 visit.

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The patient was seen in the orthopedic clinic today for an urgent level 3 visit. He was walking up his driveway when he slipped and fell, landing on his left arm and striking his head against the car. He was unconscious for less than 10 minutes, experienced dizziness and vomiting, and felt severe pain in his left arm. The patient's wife was actually coming here today for follow-up of her rheumatoid arthritis, and asked that we evaluate her husband's injuries. Examination of the head reveals a 2.5 cm superficial laceration of the scalp, temporal region, left side. Examination of the left arm reveals restriction of motion and acute pain upon palpation and with attempted range of motion of the upper arm and shoulder. The patient underwent a skull x-ray to rule out fracture and x-ray of the left arm and shoulder for evaluation of the pain. The patient was taken to the radiography department where x-ray was negative for skull fracture, revealing only swelling in the area of the laceration. An x-ray of the left arm and shoulder, however, revealed an undisplaced fracture of the proximal left humerus at the greater tuberosity. Concussion. Superficial laceration of scalp, 2.5 cm. Nondisplaced fracture of proximal left humerus at the greater tuberosity. The patient underwent simple repair of the scalp laceration with sutures. The left arm was manipulated slightly to acheive proper anatomic alignment of the proximal humerus. The arm and shoulder were immobilized with sling and binder. The patient was given pain medication, and the patient's wife was instructed on how to perform neuro checks every two hours on the patient for the next 24 hours. Assign CPT/HCPSC Level II and ICD-10-CM codes. The patient was seen in the orthopedic clinic today for an urgent level 3 visit. He was walking up his driveway when he slipped and fell, landing on his left arm and striking his head against the car. He was unconscious for less than 10 minutes, experienced dizziness and vomiting, and felt severe pain in his left arm. The patient's wife was actually coming here today for follow-up of her rheumatoid arthritis, and asked that we evaluate her husband's injuries. Examination of the head reveals a 2.5 cm superficial laceration of the scalp, temporal region, left side. Examination of the left arm reveals restriction of motion and acute pain upon palpation and with attempted range of motion of the upper arm and shoulder. The patient underwent a skull x-ray to rule out fracture and x-ray of the left arm and shoulder for evaluation of the pain. The patient was taken to the radiography department where x-ray was negative for skull fracture, revealing only swelling in the area of the laceration. An x-ray of the left arm and shoulder, however, revealed an undisplaced fracture of the proximal left humerus at the greater tuberosity. Concussion. Superficial laceration of scalp, 2.5 cm. Nondisplaced fracture of proximal left humerus at the greater tuberosity. The patient underwent simple repair of the scalp laceration with sutures. The left arm was manipulated slightly to acheive proper anatomic alignment of the proximal humerus. The arm and shoulder were immobilized with sling and binder. The patient was given pain medication, and the patient's wife was instructed on how to perform neuro checks every two hours on the patient for the next 24 hours. Assign CPT/HCPSC Level II and ICD-10-CM codes. The patient was seen in the orthopedic clinic today for an urgent level 3 visit. He was walking up his driveway when he slipped and fell, landing on his left arm and striking his head against the car. He was unconscious for less than 10 minutes, experienced dizziness and vomiting, and felt severe pain in his left arm. The patient's wife was actually coming here today for follow-up of her rheumatoid arthritis, and asked that we evaluate her husband's injuries. Examination of the head reveals a 2.5 cm superficial laceration of the scalp, temporal region, left side. Examination of the left arm reveals restriction of motion and acute pain upon palpation and with attempted range of motion of the upper arm and shoulder. The patient underwent a skull x-ray to rule out fracture and x-ray of the left arm and shoulder for evaluation of the pain. The patient was taken to the radiography department where x-ray was negative for skull fracture, revealing only swelling in the area of the laceration. An x-ray of the left arm and shoulder, however, revealed an undisplaced fracture of the proximal left humerus at the greater tuberosity. Concussion. Superficial laceration of scalp, 2.5 cm. Nondisplaced fracture of proximal left humerus at the greater tuberosity. The patient underwent simple repair of the scalp laceration with sutures. The left arm was manipulated slightly to acheive proper anatomic alignment of the proximal humerus. The arm and shoulder were immobilized with sling and binder. The patient was given pain medication, and the patient's wife was instructed on how to perform neuro checks every two hours on the patient for the next 24 hours. Assign CPT/HCPSC Level II and ICD-10-CM codes.

Explanation / Answer

1.Concussion-traumatic injury to head laceration in the temporal region,ICD-10-CM codesS09.90

2. HCPCS Level 2 are medical procedure codes for non physician services such as prosthetic devices and ambulance services.

CPT code for XRAY SKULL 4 views=70250

CPT Code for XRAY Shoulder 1view=73020

CPT Code for XRAY shoulder 2 views=73030

CPT Code for Fore arm=73090

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