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: CDH ICD-10 Training
Chapter 19 Injury, Poisoning and External Causes
Homework 11/21/13
1. Sprain, right wrist S63.501A
2. Non-displaced open fracture of third cervical vertebra S12.201B
3. Acute dye reaction, accidental T65.6x1A
4. Abrasion, left shoulder S40.212A
5. Foreign body, nose T17.1xxA
6. Acute, adverse reaction to streptomycin T36.5x5A
7. Splinter in scalp S00.05xA
8. Follow-up for failed intubation T88.4xxD
9. Follow-up visit for laceration with foreign body, right forearm S51.821D
10. 2nd degree burn, neck T20.27xA
11. Inpatient Admission: The patient, an elderly woman, was cleaning the bathroom and fell backward into the bathtub at her home. She was admitted with possible compression fractures of the lumbar spine. She had had several similar falls in the past due to frequent transient ischemic attacks. She lives alone in a single-family residence. X-rays of the spine showed some degenerative disk disease of L4 and L5, but there were no fractures. She was treated for pain and released after two days.
Discharge diagnoses: (1) Lumbar sprain injury to back, (2) probable transient ischemic attack.
S33.5xxA Sprain of ligaments of lumbar spine, initial encounter G45.9 Transient cerebral ischemic attack, unspecified W18.12xA Fall from or off toilet with subsequent striking against object, initial encounter Y92.012 Bathroom of single-family (private) house as the place of occurrence of the external cause Z91.81 History of falling Y93.E5 Floor mopping and cleaning Y99.8 Other external cause status
Comments: The compression fractures were ruled out; therefore, no codes are assigned. In ICD-10-CM the injury code has a seventh-character value to indicate the status of the encounter. This is the initial encounter for the injury, so placeholder "x" is used as needed to allow the seventh-character value to be applied. For the External cause of injury code, again the placeholder "x" is used before the seventh character for initial encounter.
The "probable" transient ischemic attack is coded as an established diagnosis because it is listed as a final diagnosis for an inpatient admission, and the summary strongly implies that the fall was probably due to another such attack. The radiology report contained incidental findings of degenerative disk disease that was not treated or further evaluated; therefore, no code is assigned for this condition. Code Z91.81, History of falling, is added because the patient has had several similar falls in the past. An activity code and activity status are added for the case.
Although the fractures were located in the lumbar area, the summary does not specify the area included in the X-ray.
12. Inpatient admission: The woman suffered a displaced fracture dislocation of her right ankle. The injury happened when she jumped off her single-family home front porch in an attempt to catch her fleeing dog, who was being given a bath. She underwent an open reduction and internal fixation of the fracture and was treated with elevation, bed rest, analgesics, and antibiotics. She was released in stable condition.
Discharge diagnosis: Trimalleolar fracture dislocation, right ankle.
S82.851A Displaced trimalleolar fracture of right lower leg, initial encounter for closed fracture W13.8xxA Fall from, out of or through other building or structure, initial encounter Y92.018 Other place in single-family (private) house as the place of occurrence of the external cause Y93.K9 Activity, other involving animal care Y99.8 Other external cause status
Comments: A trimalleolar fracture involves the medial, lateral, and posterior malleoli of the tibia. A fracture dislocation is coded to fracture. A displaced fracture is a closed fracture.
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