A 54-year-old patient presented to the emergency room with a gunshot wound in the back exiting through the front. A CT scan shows some renal damage to the right kidney and a renal exploration is ordered. The surgeon has been called in and the patient is taken to surgery to examine the renal structure. Making an incision over the gunshot wound, the surgeon examines both the blood vessels and the kidney. The trauma has caused a hematoma to the kidney, which has not spread, so the surgeon closes and the patient is sent to the floor for observation. Select the appropriate CPT and ICD-10-CM codes.

Question

Quizplus · Accepted Answer

The correct CPT code for renal exploration due to trauma is 50010. The ICD-10-CM codes S31.001A (open wound of the front wall of the abdomen, initial encounter), S37.091A (other injury of right kidney, initial encounter), and W34.00xA (accidental discharge from other and unspecified firearms, initial encounter) accurately describe the patient's condition and the cause of the injury.

A 54-Year-Old Patient Presented to the Emergency Room with a Gunshot