ED Coding and Reimbursement Alert
Nail Dx for Complicated Facial Injury Presentation
Question: What ICD-10 codes would you assign to the following case?
Hx. of present illness. This is a 52-year-old man who was involved in an interpersonal altercation about 1:30 AM this morning. He was presented to the ED with complaints of pain and swelling to the right side of the face. He had been struck with the butt of a handgun. Witnessed stated he did not lose consciousness, and he also stated he did not lose consciousness. This injury showed pain and edema in the temporal area region, in addition to pain and swelling to the right eye. Small abrasion-noted on the top of the head and right forehead. No laceration noted. He had no dyslopia. His past medical history and Surgical history were-noncontributory. No Known Medications taken, and is NKA at this time.
X-rays, CT scan revealed a nondisplaced Zygomatic Fracture and an orbital floor fracture with a slight limitation of his upper gaze. He was admitted to the OR for further treatment of his injuries.
Final DX: Right orbital fracture, right zygomatic fracture and abrasion on his head.
New York Subscriber
Answer: To find the ICD-10 codes, let’s start with what we would assign using ICD-9. You would report:
Now expanding those to reflect ICD-10’s increased granularity, you would report:
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Nail Dx for Complicated Facial Injury Presentation
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