Case 1 Patient Information: Name: Louise Samuels Address: 12…
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Cаse 1 Pаtient Infоrmаtiоn: Name: Lоuise Samuels Address: 12347 Morning Circle Drive City: Anywhere State: MO Zip: 877671234 Telephone: 797-977-3154 Gender: Female Status: Married Date of Birth: 10/6/1952 Employer: Retired Work Related: No Auto Accident: No Other Accident: Yes Date of Accident: 5/29/20XX Referring Physician: Address: Telephone: NPI #: Insurance Information: Primary Insurance: Medicare Policy #: 779873113B Group #: Name of Insured: Self DOS: 5/3/20XX History of Present Illness: This is a 65-year-old female who was cutting onions at home this evening and accidently sliced her left index finger. She also is experiencing continued eye irritation from the onions that has not resolved. She presents now for evaluation of the laceration and bilateral eye irritation. She states she can see but needs to close her eyes to alleviate the discomfort. She has not taken any medications at home. She has a cloth wrapped around her left index finger that is saturated in blood. She does normally wear contact lenses but was able to remove them prior to arrival. Review of Systems: As stated above. Past Medical History: Immunizations are up to date. Past Surgical History: None. Social History: Patient does not smoke, she does not drink alcohol, and she does not use drugs. She is retired. Medications: None. Allergies: No known drug allergies. Physical Examination: Vital Signs: Blood pressure 138/86, pulse 67, temperature is 97, respiratory rate 18, 02 100. HEENT: Eyes: Right eye vision 20/25; left eye 20/20; both eyes 20/20. No foreign bodies seen. PERRLA at 2–3 mm. Both eyes continue to weep, and conjunctivae are inflamed bilaterally. The oral mucosa is moist and appears normal. Neck: The neck is supple, and the trachea is midline. Respiratory: Equal chest wall excursion. There are no intercostal retractions or the use of accessory muscles with respirations. Breath sounds are clear and symmetrical. There are no wheezes, rales, or rhonchi. Cardiovascular: The chest wall is normal in appearance. The heart has a regular rate and rhythm. Integumentary: Inspection of the left index finger reveals a 4 cm laceration of the dorsal surface extending into the deeper layers of the subcutaneous tissue. The abdomen is soft and nondistended. There is no tenderness to palpation, rebound or guarding. Skin: There is no significant rash or ulceration. Neurologic: Grossly normal/baseline. Musculoskeletal: Strength and tone are grossly normal to the upper and lower extremities. Diagnostic Impression: Wound left index finger, intermediate. Eye inflammation, conjunctivitis due to exposure. Urgent Care Course: The 4 cm wound was injected with 1% lidocaine without epinephrine achieving complete numbing of the area. The wound was irrigated with Betadine and normal saline and surrounding skin prepped with Betadine. The wound was explored to base using pickups to visualize and palpate. No foreign body noted. No evidence of major vascular or nerve injury identified. Wound edges approximated and closed in layers with 6 running 4-0 Vicryl, 7 interrupted sutures with 6-0 Nylon. Bacitracin ointment and dry sterile dressing applied. The patient tolerated the procedure well. Gentamicin ophthalmic drops were administered OU. Inflammation beginning to subside prior to discharge. Final Diagnosis: Finger laceration, 4.5 cm, intermediate repair; inflammation of eyes with redness and discharge. Robert Swift, MD Practice: Urgent Care Clinic Review the chart note and the claim form that is provided for this patient. Are there any elements that are incorrect? Primary insurance Primary insurance ID number Signature on File Place of service Date of service or date of injury Billing provider information CPT® codes Modifier Diagnosis code A. I, VII, VIII B. III, IV, V, VIII C. III, VII, VIII, IX D. II, III, IV, VI, VII