Outpatient—Physician’s Office (Musculoskeletal) Patient Name: Brad Ferrington Diagnosis: Dislocated right shoulder Procedure: Closed reduction of dislocated right shoulder with provision of sling An established patient presented to his primary doctor with pain in his right shoulder. He said he was driving his car to the store the day before to pick up some milk for his wife when another car exiting the parking lot hit his car. He said that his left shoulder hit the driver’s side door and that he could not understand why his right shoulder hurt so much. A complete shoulder x-ray performed in the office confirmed a dislocation of the right shoulder. The physician explained that indirect force was expelled when he hit his left shoulder, and this actually caused the dislocation of the right shoulder. The doctor performed a closed reduction of the shoulder and placed the arm in a sling. The physician then continued with the level 3 office evaluation and management service, which include an appropriate history and examination, to ensure that there were no other injuries. The physician instructed the patient to use ice and take Tylenol for pain. Instructions: Assign ICD-10-CM, CPT, and HCPCS level II codes for this case, including ICD-10-CM external cause codes. Please be aware that when an answer consists of more than one code, there will be an answer blank for each code. ICD-10-CM: , , CPT: , , HCPCS Level II:
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