would you code 12011 or bundle the procedure with the E/M?
16 y/o female brought to ER after altercation at party. Pt states accidentally hit in face causing L brow lac. No LOC, no neck or back pain, no N/V, W/N or other complaints. Pt denies vision change. Her last Td was within 10 years. Consent obtained verbally by RN from parent to treat.
Review of Systems
HENT: Positive for headaches.
Eyes: Negative for blurred vision, double vision and eye pain.
Cardiovascular: Negative for chest pain.
Respiratory: Is not experiencing shortness of breath.
Gastrointestinal: Negative for nausea and vomiting.
Neurological: Negative for sensory change, focal weakness and loss of consciousness.
Past Medical History
Asthma
Meds:
OCP's
Albuterol
Allergies:
NKDA
BP 124/72 | Pulse 68 | Temp 98.3 °F (36.8 °C) | Resp 16 | Wt 49.896 kg (110 lb) | SpO2 100%
Physical Exam
Vitals reviewed.
Constitutional: She is oriented. She appears well-developed and well-nourished. She appears not diaphoretic. No distress.
HENT:
Head:
Pt has 1 cm L brow/lid laceration below eyebrow as indicated on diagram. No active bleeding or visible fat. Slight surrounding ST swelling.
Eyes: Extraocular motions are normal. Pupils are equal, round, and reactive to light.
Neck: No spinous process tenderness present.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds.
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has no wheezes.
Abdominal: Bowel sounds are normal. She exhibits no distension. Soft. No tenderness.
Musculoskeletal: Normal range of motion.
Neurological: She is alert and oriented. She has normal strength. No cranial nerve deficit. GCS eye subscore is 4. GCS verbal subscore is 5. GCS motor subscore is 6.
Skin: Skin is warm and dry. No rash noted. She is not diaphoretic.
Psychiatric: She has a normal mood and affect. Her behavior is normal. Judgment and thought content normal.
ASSESSMENT:
16 y/o female s/p L brow laceration during altercation. Police were at seen per patient, did not want to make report
PLAN:
Dermabond applied to close wound. Tolerated well. Pt told to monitor for increased pain, swelling, fever, redness, or pus draining from wound and return.
16 y/o female brought to ER after altercation at party. Pt states accidentally hit in face causing L brow lac. No LOC, no neck or back pain, no N/V, W/N or other complaints. Pt denies vision change. Her last Td was within 10 years. Consent obtained verbally by RN from parent to treat.
Review of Systems
HENT: Positive for headaches.
Eyes: Negative for blurred vision, double vision and eye pain.
Cardiovascular: Negative for chest pain.
Respiratory: Is not experiencing shortness of breath.
Gastrointestinal: Negative for nausea and vomiting.
Neurological: Negative for sensory change, focal weakness and loss of consciousness.
Past Medical History
Asthma
Meds:
OCP's
Albuterol
Allergies:
NKDA
BP 124/72 | Pulse 68 | Temp 98.3 °F (36.8 °C) | Resp 16 | Wt 49.896 kg (110 lb) | SpO2 100%
Physical Exam
Vitals reviewed.
Constitutional: She is oriented. She appears well-developed and well-nourished. She appears not diaphoretic. No distress.
HENT:
Head:
Pt has 1 cm L brow/lid laceration below eyebrow as indicated on diagram. No active bleeding or visible fat. Slight surrounding ST swelling.
Eyes: Extraocular motions are normal. Pupils are equal, round, and reactive to light.
Neck: No spinous process tenderness present.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds.
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has no wheezes.
Abdominal: Bowel sounds are normal. She exhibits no distension. Soft. No tenderness.
Musculoskeletal: Normal range of motion.
Neurological: She is alert and oriented. She has normal strength. No cranial nerve deficit. GCS eye subscore is 4. GCS verbal subscore is 5. GCS motor subscore is 6.
Skin: Skin is warm and dry. No rash noted. She is not diaphoretic.
Psychiatric: She has a normal mood and affect. Her behavior is normal. Judgment and thought content normal.
ASSESSMENT:
16 y/o female s/p L brow laceration during altercation. Police were at seen per patient, did not want to make report
PLAN:
Dermabond applied to close wound. Tolerated well. Pt told to monitor for increased pain, swelling, fever, redness, or pus draining from wound and return.