S: This new patient got into a fight a week ago, smacked a person and had his left third knuckle cut with a tooth. This has been red and swollen for the last couple of days. Today it is much redder and much more swollen. lt is very tender

Question

PAST MEDICAL HISTORY: No medical problems.
MEDICATIONS: NONE.
ALLERGIES: NONE.
O: VITAL SIGNS: As noted.
HEENT: Unremarkable.
LUNGS: Clear.
HEART: Regular rate and rhythm.
EXTREMETIES: The left knuckle over the metacarpophalangeal joint is erythematous approximately 7 cm patch with a little bit of swelling right over the joint. It is very tender to touch.
A: Cellulitis of the left hand.
P: We will put him on Cephalexin 500 two pills three times a day for 10 days.
We gave him Lortab 7.5 very 4–6 hours as needed for pain. He is to keep heat on this and follow up in 48 hours. If he is getting worse, he should come back sooner.
ICD-9-CM diagnosis code(s): _____________________
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ICD-10-CM diagnosis code(s): _____________________
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CPT code(s) with modifier, if applicable: _____________________

What will be an ideal response?

Answer 1

Answers:
ICD-9-CM diagnosis code(s): _681.00, E960.0
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ICD-10-CM diagnosis code(s): L03.012, Y04.0XXA
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CPT code(s) with modifier, if applicable: 99203