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

50010 is the correct CPT code for renal exploration due to trauma with no mention of repair, which matches the scenario described. S31.001A and S37.091A are the correct ICD-10-CM codes for an unspecified open wound of the abdomen and unspecified injury of right kidney, respectively, both initial encounters, which align with the patient's condition. W34.00xA is the correct code for an accidental discharge of a firearm, unspecified, initial encounter, which matches the cause of the injury.

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