DISCHARGE SUMMARY

The patient is a 62-year-old female who fell while walking her dog. She was walking on the sidewalk in her neighborhood and accidently slipped and fell. 

She sustained a comminuted fracture of the shaft of her right tibia confirmed by x-ray done in the emergency room. She also hit her head on a fire hydrant and suffered a slight concussion but no loss of consciousness. 

She also had a laceration down to the fascia on her right hand, which needed repair with sutures in the ED.

The patient was admitted and taken to surgery, where an open reduction with internal fixation of the shaft of the right tibia was accomplished with good alignment of fracture fragments. 

Her chronic conditions of diabetes, CHF, and hypertension were managed with home medications.

Postop course was uneventful, and the patient was discharged home with daily physical therapy.

Procedures:

1. ORIF of Right Tibia Shaft
2. Open Repair of subcutaneous tissue and fascia of right hand

Answers:

1. S82.251A Fracture, traumatic, tibia (shaft), comminuted (displaced). Review Tabular for correct code assignment. This is the Pdx.
2. S06.0X0A Concussion (brain) (cerebral) (current), without loss of consciousness. Review Tabular for correct code assignment.
3. I50.9 Congestive Heart Failure NOS
4. S61.411A Laceration without a foreign body on the right hand during an initial encounter
5. I11.0 Hypertensive heart disease with heart failure
6. E11.9 Diabetes mellitus unspecified
7. W01.198A Index to External Causes, Fall, due to, slipping, with subsequent striking against ob-ject, specified NEC. Review Tabular for correct code assignment.
8. Y92.480 Index to External Causes, Place of occurrence, sidewalk
9. Y93.K1 Index to External Causes, Activity, walking an animal
10. Y99.8 Index to External Causes, External cause status, leisure activity

Procedures:

1. 0QSG04Z Reposition, Tibia, Right (0QSG) Reduction, Fracture see Reposition
2. 0JQJ0ZZ Repair, Subcutaneous Tissue and Fascia, Right Hand, Open Approach

Rationale:

Diagnoses:

The reason for the admission was a fracture of the shaft of the right tibia, which codes to S82.251 with the sixth digit indicating the right side.

The fracture code requires a seventh character (code extension). The code extension A is used on the fracture code to indicate that this is the initial encounter for a closed fracture.

The notes under S82 instruct the coder to code the fracture as closed if the documentation does not designate whether open or closed. An additional note indicates that a fracture not identified as displaced or nondisplaced should be coded to displaced.

The patient has both hypertension and CHF. Even though the provider may not link them, due to the "with" convention, they are coded as linked (unless provider unlinks them). That leads to code I11.0 for the hypertension and I50.9 for CHF unspecified.

W01.198A is the external cause of injury code for tripping, falling, and subsequently hitting her head on the fire hydrant.

Code Y92.480 indicates the place of occurrence for the injury. A note under Y92 indicates that a place of occurrence code should be recorded only at the initial encounter for treatment.

An additional note under Y92 states to use in conjunction with an activity code. Activity code Y93.K1 is coded because the patient was walking her dog when the injury occurred.

A note under Y93 states that activity codes should be used in conjunction with codes for external cause status (Y99) and place of occurrence (Y92).

The external cause status code is Y99.8.

Procedures:

The open reduction with internal fixation of the tibial fracture is coded to 0QSG04Z. The correct root operation is Reposition, which is defined as moving to its normal location or other suitable location all or a portion of a body part.

Repair of laceration of the subcutaneous tissue is coded to the root operation repair, and the body system, subcutaneous tissue and fascia, and the body part is hand.