Musculoskeletal System-Case 2

Assign an external cause code to indicate how the injury occurred.

LOCATION: Inpatient, Hospital

PATIENT: Tara Barron

ATTENDING PHYSICIAN: Gary Sanchez, MD

SURGEON: Gary Sanchez, MD

PREOPERATIVE DIAGNOSIS: Stab wound, right upper abdominal quadrant.

POSTOPERATIVE DIAGNOSIS: Same as Preoperative.

PROCEDURE PERFORMED: Exploration of stab wound, right upper quadrant of abdomen, with closure of fascial defect.

ANESTHESIA: General.

PROCEDURE: The patient was brought to the operating room and placed under general anesthesia; we then removed the jar lid from around the knife as well as the patients clothing, and prepped with Betadine solution. We extended the incision on either side of the right upper quadrant stab wound 2-3 cm and carried the dissection through subcutaneous tissues using electrocautery. We followed the knife down along its tract and then could see the knife had penetrated the anterior sheath and the rectus fascia by about a quarter inch. We removed the knife and could see the tip was just within the rectus muscle. There was no peritoneal penetration. We then closed the fascia with interrupted 0 Vicryl and closed the skin with vertical mattress 30 Ethilon sutures.

All sponge and needle counts were correct. Patient tolerated this well and was taken to recovery in stable condition.

Assign the CPT code for Case-2: ______________

Assign the first-listed ICD-10-CM code for Case-2: ___________

Assign the additional ICD-10-CM code for Case-2: ___________

Abstracting Questions:

1. What is the main term referenced in the CPT coding manual for the procedure in Case-2?

2. What is the secondary term reference in the CPT coding manual to report the procedure in Case-2?

3. Can the repair in Case-2 be reported separately?

4. According the Case-2 medical documentation, how far had the knife penetrated?