Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD$-10-$CM code$($s$)$ and external cause code$($s$)$ if appropriate. Answer each question as it guides you through the coding process. Remember; check the chapter specific, sub$-$chapter specific and category specific notations within the Tabular list.

Billy Ugro, a $7-$year$-$old male, was brought in by his mother. Billy was playing this afternoon in his backyard on the sliding board and fell, scraping his left cheek. Dr$.$ Tucker, his pediatrician, examines the area and cleans and dresses the wound. Billy is diagnosed with a second$-$degree abrasion.

Be sure to list the codes, one code per box, in the correct sequence. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices.

Principal diagnosis

Where should you begin to look up the code in the coding manual?

Index to Diseases and Injuries

What is the key term?

Abrasion

What is the anatomical site?

Cheek

What degree

Second

Do any of the following apply to the condition?

None of these

What is the laterality?

Left

Do any of the following apply to the condition?

Initial encounter

Begin to code the encounter.

Did you verify the code in the Tabular List of Diseases and Injuries?

Yes

Is there an Includes notation?

Yes

If so does the Includes note help to clarify?

No

Is there a Code first notation?

No

If so does the Code first note apply to the case study?

No Code first note

Is there a Code also notation?

Yes

If so does the Code also note apply to the case study?

No

Is there a Use additional code notation?

Yes

If so does the Use additional code note apply to the case study?

No

Is there an Excludes$1$ notation?

Yes

If so does the Excludes$1$ note apply to the case study?

No

Is there an Excludes$2$ notation?

Yes

If so does the Excludes$2$ note apply to the case study?

No

Is there a symbol indicating additional characters are required?

Yes

Do you need to use the placeholder $$X$?$

Yes

Did you code to the highest level of specificity?

Yes

What is the correct diagnosis code?

S$00\mathrm{.}81$XA

Second diagnosis

Where should you begin to look up the code in the coding manual?

External cause of injuries index

What is the key term?

Fall from

What?

Playground equipment

What type?

Slide

Do any of the following apply to the condition?

Initial encounter

Begin to code the encounter.

Did you verify the code in the Tabular List of Diseases and Injuries?

Yes

Is there an Includes notation?

$($Click to select$)$

If so does the Includes note help to clarify?

$($Click to select$)$

Is there a Code first notation?

$($Click to select$)$

If so does the Code first note apply to the case study?

$($Click to select$)$

Is there a Code also notation?

$($Click to select$)$

If so does the Code also note apply to the case study?

$($Click to select$)$

Is there a Use additional code notation?

$($Click to select$)$

If so does the Use additional code note apply to the case study?

$($Click to select$)$

Is there an Excludes$1$ notation?

$($Click to select$)$

If so does the Excludes$1$ note apply to the case study?

$($Click to select$)$

Is there an Excludes$2$ notation?

$($Click to select$)$

If so does the Excludes$2$ note apply to the case study?

$($Click to select$)$

Is there a symbol indicating additional characters are required?

$($Click to select$)$

Do you need to use the placeholder $$X$?$

$($Click to select$)$

Did you code to the highest level of specificity?

$($Click to select$)$

What is the correct diagnosis code?

Third diagnosis

Where should you begin to look up the code in the coding manual?

$($Click to select$)$

What is the Place of Occurrence?

$($Click to select$)$

What type?

$($Click to select$)$

Where?

$($Click to select$)$

Begin to code the encounter.

Did you verify the code in the Tabular List of Diseases and Injuries?

$($Click to select$)$

Is there an Includes notation?

$($Click to select$)$

If so does the Includes note help to clarify?

$($Click to select$)$

Is there a Code first notation?

$($Click to select$)$

If so does the Code first note apply to the case study?

$($Click to select$)$

Is there a Code also notation?

$($Click to select$)$

If so does the Code also note apply to the case study?

$($Click to select$)$

Is there a Use additional code notation?

$($Click to select$)$

If so does the Use additional code note apply to the case study?