This is an authentic coding case for an Inpatient Clinic for Musculoskeletal System. Please review
This is an authentic coding case for an Inpatient Clinic for Musculoskeletal System. Please review the documentation of the patient encounter and code the case.You will use 7 ICD-10-CM codes and 4 ICD-10-PCS codes PRINCIPAL OR FINAL DIAGNOSIS: Left proximal tibia physeal bar with procurvatum deformity and knee flexion contracture SECONDARY DIAGNOSES: None HISTORY OF PRESENT ILLNESS: a 12 year old male with history of MVA with associated TBI and left SH IV distal femur fracture and SH V proximal tibia fracture. has developed left proximal tibia physeal bar and proximal tibial procurvatum and varus. is indicated for left proximal tibia osteotomy and right proximal tibia epiphysiodesis for leg length difference. HOSPITAL COURSE: Patient was admitted post-operatively under care of Orthopedics. Acute Pain Service managed epidural for pain control. On POD #2 patient successfully transitioned to oral pain medications. Patient met all PT goals on POD #2. Patient was discharged to home on POD #3 in good condition. OPERATIVE PROCEDURES: Epiphysiodesis R proximal tibia/fibula and L proximal tibia anterior closing wedge osteotomy, proximal fibula osteotomy, and patellar advancement Health Science Science Nursing HCMT 2025C Share QuestionEmailCopy link Comments (0)
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