Assign the ICD-10-CM code(s) according to outpatient codingguidelines (e.g., assign codes to signs and symptoms when adiagnosis has not been established), and assign the CPT evaluationand management code(s) and appropriate modifier(s). Do not assignICD-10-CM external cause codes.Gerry Smith w’as seen in theemergency department (ED) following a house fire. The patientsustained thirddegree burns over 20 percent of his body andsecond-degree burns over 10 percent of his body, resulting in atotal of 30 percent of his body being burned. Based on informationobtained from the patient’s Medic Alert bracelet, the patient hastype 2 diabetes mellitus and a heart condition. The ED physiciandocumented a detailed examination and medical decision making ofhigh complexity. The patient was unable to provide any history dueto severe pain, which made it impossible for him to speak.Therefore, the ED physician obtained a detailed history from thepatient’s spouse. The ED physician documented a total of 80 minutesspent with this patient before the patient was transferred to thehospital’s inpatient burn unit. During the 80 minutes, the patienthad an episode of ventricular tachycardia, which converted withmedication. The patient’s blood sugar was closely monitored in theED.
