I'm not sure what dx codes to use for the document below:
History: 31-year-old man status post gunshot wound, status post transanal rectal injury repair
Impression:
1. High right superior pubic ramus fracture with adjacent intramuscular and extraperitoneal hemorrhage.
2. Rectal wall thickening and presacral hemorrhage.
3. Fracture fragments and/or foreign bodies within the right pectineus and right obturator muscles.
Greatly appreciate it!
Thank you,
Salima H., CPC
Radiology Coding Specialist
History: 31-year-old man status post gunshot wound, status post transanal rectal injury repair
Impression:
1. High right superior pubic ramus fracture with adjacent intramuscular and extraperitoneal hemorrhage.
2. Rectal wall thickening and presacral hemorrhage.
3. Fracture fragments and/or foreign bodies within the right pectineus and right obturator muscles.
Greatly appreciate it!
Thank you,
Salima H., CPC
Radiology Coding Specialist