CODING SAMPLE

This sample shows the chart note, the logic used to code and the various codes used to bill the insurance company.

This is the encounter description from the chart (medical office visit)

The patient is a 7-year-old male who has not been seen in our office before who fell off a bicycle, hit his head on the cement and sustained a scalp laceration. He states his head hurts. The wound is linear through the skin and subcutaneous tissue. The child was examined. He has a 3 x 3 cm bump, however, examination of the eyes shows pupils equal and reactive to light and accommodation. No further workup of the head injury will be done; however, the mom was instructed as to signs and symptoms of concussion. The wound was noted to be 2 cm; it was cleansed with Hibicleans. The area around the wound was infiltrated with 1% Xylocaine with epinephrine. It was repaired with #1-0 chromic and a dressing was placed. The stitches will be removed in 10 days. 

NOTE:

  • the patient had not been seen before
  • the patient was seen in the office (not the hospital)
  • he hit his head with a possibility of concussion
  • he has a laceration which was repaired
  • he fell off a bicycle

Rationale:

1. CPT CODE: The provider will bill for the above problems and treatments. The first code selected would be the exam code for the head injury. The head was examined, and the eyes were tested to rule out any obvious brain injury. Looking at the Evaluation and Management Codes, 99201 to 99205, (procedures performed in the office) the complaint and history are pretty straightforward, and the exam dealt only with the body area involved (the head).  The decision-making process (diagnosis and treatment) was also straightforward so 99202 is the best choice. 

DIAGNOSIS: The diagnosis for the head injury is a little more complicated: No specificity as to whether a concussion occurred or not so the ICD-9 code choice is a general one, 959.01 (injury – not otherwise specified). (We don’t know about any actual intracranial injury at this point.)

Converting the ICD-9 code 959.01 to the ICD-10 code. 

ICD-9-CM 959.01 converts in ICD-10 approximately to:

  • S09.90XA Unspecified injury of head, initial encounter

2. In conjunction with the injury, you would have used the ICD-9 E-codes to describe how the injury occurred. In this case, he fell off a bicycle. This would be coded E826, Bicycle accident, requiring an extension of .1, E826.1, showing the child was the bicyclist. The ICD-10 is V10.0XXA.

3. CPT is used to describe the wound closure. Looking at the “repair” codes, you would see these options: 

CODE | DESCRIPTION (and size)

12001*

  • Simple repair of wound of scalp, neck axillae, external genitalia, trunk and/or extremities (including hands and feet) 2.5 cm or less

12002*

  • 2.6 cm to 7.5 cm

12004*

  • 7.6 cm to 20.0 cm

We know the wound was of the scalp, and was 2 cm in length, so we select 12001

4. ICD Code for the laceration which has to be the counterpart entry to the CPT laceration repair. The wound code is located under Wound, open, scalp in the and the ICD-10 code is S01.00XA.
 

CPT CODE (Physician charges) | DIAGNOSIS

99202

  • E826.1, 873.0 (ICD-9 codes), V10.0XXA (ICD-10)
  • And 959.01 (ICD-9), S09.90XA (ICD-10)

12001

  • S01.OOXA                                     

5. HOSPITAL CHARGES

If this service was provided in the hospital, the coder would be dealing with only the hospital charges (room, supplies, materials, etc.) unless the hospital also billed for the physician services; then the procedure ICD-9-Volume 3 or the ICD-10-PCS codes would be used. In the ICD-9 version, you would find in the index, “repair,” then locate wound (without graft), finding 86.59. In the numeric index, locating 86, Operations on skin and subcutaneous tissue, moving through the various subcategories, you would see the 86.59, suture of skin and subcutaneous tissue of other sites. The same is true for the PCS codes. 

For the procedure, 86.59 is the PCS code, plus any supplies, room charges, suture material, syringe, deadening agent, etc., converting to OHQ1XZZ.

ICD-10 Code: Query would be “wound or laceration of the scalp” and S01.01XA is used, laceration without foreign body, scalp, initial encounter.