The pаtient is а 50-yeаr-оld female whо was previоusly treated by closed reduction and external fixation of a fracture of her right tibia, distal medial malleolus. During follow-up care, it becomes evident the fracture is not healing. X-rays demonstrate a nonunion of the right distal tibia. The patient is admitted for surgical repair of the nonunion. The surgery performed is an open reduction of the right tibia with bone grafting. Bone for the grafting is harvested from the patient’s left iliac crest. The distal medial malleolus tibial bone, at the site of the non-union, is osteotomized and repositioned. The harvested bone graft is packed into the fracture site to replace the missing bone, and three screws are inserted to secure the area. The patient is discharged the day after surgery for recovery at home. Note: List all applicable codes excluding the External Cause codes. Principal Diagnosis: Secondary Diagnoses: Principal Procedure: Secondary Procedure: Secondary Procedure: Hint: both the harvesting of the bone and the graft must be coded.
The pаtient is а 40-yeаr-оld chef at a lоcal restaurant whо was burned while at work two weeks ago and was treated by a trauma physician in the emergency department of the hospital. Today she is being seen by the same trauma physician in the trauma clinic as an outpatient to examine the healing of the burns she sustained on her right hand and wrist, right forearm, and right side of the neck. The burn dressings were removed and the burn sites were examined for evidence of healing and lack of infection. No debridement was required. Medicated ointments were applied to the burn areas and new burn dressings were applied to the three sites. The final diagnoses were documented by the physician for this follow up visit: 1. First- and second-degree burns, multiple sites on right hand and wrist, normal healing 2. First- and second-degree burns, neck, normal healing 3. First-degree burns, right forearm, normal healing Note: List all applicable codes excluding the External Cause codes. First Listed Diagnosis: Add'l Diagnosis: Add'l Diagnosis: