Question

The patient is a 44-year-old female who was working at a glass bead factory. She was using a torch and hot glass when the glass cracked. She had just come back from lunch break and had forgotten to put her safety glasses back on. The glass splintered and hit her left eye.

On examination, there is a laceration on the left eyelid, but no foreign body is found in the wound. An exam with the slit lamp notes a large sliver of glass deeply embedded in the cornea of the left eye. The laceration is cleaned in the ED and the patient is admitted for the removal of the glass in her cornea under general anesthesia.
What is the coding and sequencing of the diagnoses in this case?
A. S01.112S, T15.02XS
B. S01.112A, T15.02XA
C. T15.02XA, S01.112A
D. T15.02XS, S01.112S

Answer 1

The coding for the patient's condition with a laceration on the left eyelid and a foreign body in the left cornea is S01.112A for the eyelid laceration and T15.02XA for the corneal foreign body, both indicating initial encounters.

Step-by-step explanation:

The correct answer to the coding and sequencing of diagnoses for this patient's case is B. S01.112A, T15.02XA. In medical coding, especially following the ICD-10 guidelines, the first code represents the initial encounter for a laceration without a foreign body of the left eyelid, which is coded as S01.112A.

The patient's laceration was cleaned in the Emergency Department (ED) indicating it is the initial encounter. The second code, T15.02XA, represents a foreign body in the cornea of the left eye, also coded as an initial encounter because the removal is to be done under general anesthesia indicating systemic care due to the severity of the injury.