Answer the following questions for BOTH of the two different scenarios:

1.) How would the scenario be reported if the patient returns for a follow-up visit during the healing phase of the injury?

• Review the following guidelines: C.19.a and C.21.c.8

2.) What ICD-10-CM codes are reported?

Scenario 1: Jason is a 17-year-old football player. While playing a game with his team Jason was tackled by a member of the opposing team. When this collide happened his knee was twisted. Upon standing Jason realized that he could not put any pressure on his left knee. This caused him to be taken out of the game and evaluated by the medical team. After the examination, the doctors decided that Jason needed to go to the hospital as they suspected a dislocated patella.

• Cause: American Tackle Football: Y93.61 – Activity, American tackle football
• Intent: accidental
• Place: Football Field Y92.321 – Football field as the place of occurrence of external cause
• Activity: Football game
• Diagnosis: Left patella dislocation – S83.015A – Lateral dislocation of left patella
• External cause: Tackle from the opposing team Y99.8 – Other External cause (Student)

Scenario 2: Patient is a male middle school student rushed in from a bus accident. His right leg has been fractured causing a minor break in the tibia. He mentioned he was sitting on the outside of row when bus turned over after being struck by van, and leg was struck by falling bookbag slamming leg into railing under seat causing him extreme pain.

• Injury code: S82.201A -Unspecified Fracture of shaft of the right tibia

It’s an unspecified fracture of the shaft because there is nothing stating whether it was obliques, transverse etc.

• Activity: Y93.89 – Activity, Other specified

The reason I chose this code because there is no specific stating the activity of sitting on a bus or transportation sitting.

• Intent:  V73.6XXA- Passenger on bus injured in collision with car, pickup truck, or van in traffic accident.

The reason I chose these codes because the patient was on the bus when he was injured and it collided with a van on accident.

• Cause: W20.8XXA- Other cause of strike by thrown, falling or projected object.

The patient’s injury was caused by an object falling and striking his leg.

• Place of Occurrence: Y92.811- Bus as the place of occurrence of external activity

The patient acquired his injury on the bus.

Whichever tutor assists me I will leave a review once I check the accuracy and understanding. Thank you.

ANSWER

Scenario 1: Follow-Up Visit During Healing Phase

Reporting the Scenario

In the follow-up visit during the healing phase of Jason’s injury, the medical record would document his progress and the ongoing care provided for his left patella dislocation. The documentation should highlight the improvement in his condition, any interventions administered, and the expected outcomes. This report would ensure continuity of care and serve as a reference for future assessments.

ICD-10-CM Codes Reported

1. External Cause: American Tackle Football: Y93.61 – Activity, American tackle football
2. Intent: Accidental
3. Place: Football Field Y92.321 – Football field as the place of occurrence of external cause
4. Activity: Football game
5. Diagnosis: Left patella dislocation – S83.015A – Lateral dislocation of left patella
6. External Cause: Tackle from the opposing team Y99.8 – Other external cause (Student)

Scenario 2: Follow-Up Visit During Healing Phase

Reporting the Scenario

For the follow-up visit during the healing phase of the patient’s fractured right tibia due to a bus accident, the medical record would detail the progress of the patient’s recovery. It would emphasize the management provided, any interventions undertaken, and the status of his fracture healing process. This report would ensure a comprehensive overview of his healing journey.

ICD-10-CM Codes Reported

1. Injury Code: S82.201A – Unspecified Fracture of shaft of the right tibia
Rationale: Unspecified fracture of the shaft due to lack of specificity regarding the type of fracture.

2. Activity:Y93.89 – Activity, Other specified
Rationale: Chosen because there is no specific code for sitting on a bus or transportation sitting.

3. Intent: V73.6XXA – Passenger on bus injured in collision with car, pickup truck, or van in traffic accident.
Rationale: Selected because the patient was a passenger on the bus and the accident involved a van.

4. Cause: W20.8XXA – Other cause of strike by thrown, falling, or projected object.
Rationale: The patient’s injury was caused by a falling object striking his leg.

5. Place of Occurrence: Y92.811 – Bus as the place of occurrence of external activity
Rationale: The patient acquired his injury on the bus.

Conclusion

Effective reporting and documentation of patient scenarios during follow-up visits are essential for tracking their progress, managing their care, and ensuring accurate reimbursement. Proper use of ICD-10-CM codes and external cause codes provides a comprehensive view of the patient’s history and circumstances, facilitating efficient communication among healthcare providers and ensuring quality care delivery.