On Monday, Junior and Bubba’s grandmother brings Junior in with concern of a head injury (S09.90XA). Grandmother explains that she took the boys to an indoor amusement park (Y92.831) with a carousel. While riding the carousel, Junior decided to move from one horse to another and was hit in the head by a flying horse (W31.81XA). Junior did not lose consciousness, but his scalp is tender to touch. Dr Claus obtains a complete patient history. A detailed examination is performed, and Dr Claus determines that there are no signs of skull damage or intracranial injury. Junior is diagnosed with a contusion of the scalp (S00.03XA). Dr Claus bills for a new patient office visit with a complete history, detailed examination, and low medical decision-making (99203).

On Tuesday, Junior and Bubba played inside at their grandparent’s home (Y92.009), where...

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