Outpatient-Ambulatory Surgery (Musculoskeletal) Patient Name: Loretta Michaels Diagnosis: Torn medial collateral ligament of the left knee Procedure: Repair of medial collateral ligament, left knee A 24-year-old patient twisted her knee while attempting a new ski maneuver activity. The patient underwent various forms of noninvasive treatment, for which there was only limited recovery. Due to the patient's active lifestyle, surgical repair was indicated. The patient underwent outpatient surgical repair of the medial collateral ligament of the left knee. She was suggested for a derotation knee brace and advised to follow up with her primary care provider to begin physical therapy to strengthen the knee. Instructions: Assign ICD-10-CM, CPT, and HCPCS level il codes for this case, including ICD-10-CM external cause codes. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code.
Outpatient-Emergency Department (Nervous) Patient Name: Rodney Hutchinson Diagnosis: Brainstem herniation Procedure: Magnetic Resonance Imaging (MRI), brain A 40-year-old male patient was brought to the emergency department (ED) via ambulance after he fell at home and hit his head on the edge of the bathtub at home. His wife stated that he was unconscious for an undetermined amount of time when she found him. The ED physician performed a detailed history and physical and noted that the patient scored a 9 on the Glasgow Coma Scale. An initial dose of 50 mg of phenytoin was administered via slow intravenous (IV) push. The physician also ordered an MRI, which revealed a brainstem herniation. The medical decision making for this case was high complexity. Instructions: Assign ICD-10-CM, CPT, and HCPCS level il codes for this case, including ICD-10-CM external cause codes. ICD-10-CM: CPT: HCPCS Level II:
Outpatient-Physician's Office (Circulatory) Patient Name: Wilbur Glendale Diagnosis: Asystole Procedure: Electrocardiogram A 78-year-old established male patient was brought to Dr. Smith's office by his wife after experiencing dizziness at home. His wife stated that he had been light-headed for most of the morning. During a comprehensive history and examination, the patient became extremely dizzy. The physician performed an electrocardiogram (ECG), during which the patient experienced an episode of syncope. The ECG revealed asystole, and Dr. Smith interpreted the ECG and dictated a report. Dr. Smith inserted an intravenous catheter and then administered 0.1 mg of epinephrine via IV push. The patient was then administered 0.1 mg of epinephrine via IV push x 3 every 5 minutes and cardiopulmonary resuscitation was performed. Sixty minutes of critical care was provided by Dr. Smith at the patient's bedside while his medical assistant arranged for emergency transport of the patient to Beaumont Hospital for further treatment. Medical decision making for this case was of high complexity. Instructions: Assign ICD-10-CM, CPT, and HCPCS level Il codes for this case. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code. ICD-10-CM: CPT:
Outpatient-Ambulatory Surgery (Musculoskeletal) Patient Name: Loretta Michaels Diagnosis: Torn medial collateral ligamen
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Outpatient-Ambulatory Surgery (Musculoskeletal) Patient Name: Loretta Michaels Diagnosis: Torn medial collateral ligamen
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