Answered

During a hiking trip, a patient fell and obtained a fracture of the left tibia. The patient was admitted and scheduled for a reduction of a displaced fracture with application of a cast.
Type of documentation: Diagnoses: Procedure: Coding classification system: Coding Guideline:



Answer :

Explanation:

Type of documentation: Medical record

Diagnoses: Fracture of the left tibia

Procedure: Reduction of a displaced fracture with application of a cast

Coding classification system: International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for diagnoses, Current Procedural Terminology (CPT) for procedures

Coding Guideline: Assign appropriate ICD-10-CM code(s) for the diagnosis of fracture of the left tibia, and CPT code(s) for the reduction procedure and application of cast according to the official coding guidelines and conventions.