[Verified Answer]: Dr

Dr. Wimer uses a B-scan ultrasound to assess the status of Rex’s retina while doing an eye examination. The ultrasound is reported in addition to the examination. There is an external cause code that will be assigned to this case. Report the medications given to the patient intramuscularly and intravenously with HCPCS codes. Do not report the drops that were placed in the patient’s eye, ointment, or patch. LOCATION: Outpatient, Clinic PATIENT: Rex Dagg PHYSICIAN: Rita Wimer, MD Today, I saw Rex, a 68-year-old, a new patient to me, who was wrapping a couch with a bungee cord in preparation for moving the couch, when the cord snapped and the metal fitting hit him in his left eye squarely. He has pain and loss of vision and was seen in the ED (emergency department); there was no light perception, and there was blood in the anterior chamber and a nonmoving pupil. He was sent to me, and I saw that he was 20/20 in the right and had bare light perception in the left. The pressure was 33, and there was 25% hyperemia and a vitreous hemorrhage. B-scan showed no detachment or separation of the optic nerve. I gave him 60 of Toradol IM (intramuscular) for pain and started him on Cosopt 2 drops and Iopidine 1% two drops and gave him 500 of Diamox IV (intravenous) push. Within a few minutes his pressure had reduced to 22, and the vision improved to finger counting and facial features. I placed atropine ointment, TobraDex patch, and Telfa over his eye and had him on strict bed rest without work. We will see him again in 24 hours. SERVICE CODE(S): ______________________________________ ICD-10-CM DX CODE(S): __________________________________