The patient in the example is a 7-year-old established patient with diagnoses of epistaxis (R04.0); contusion of the right periocular area, initial encounter (S00.11XA); and laceration of the lip without foreign body, initial encounter (S01.511A). The notations of “possible nasal fracture” and “rule out concussion” are not reportable for physician services based on the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) guideline for uncertain diagnosis (Section IV, H). Additionally reportable, but typically not required, ICD-10-CM external cause codes include W18.31XA (fall on same level due to stepping on an object, initial encounter), Y92.481 (parking lot as the place of occurrence of the external cause), and Y93.01 (activity walking, marching, and hiking). External cause codes may be required by state regulations in certain settings, such as the emergency department, but are not mandated by ICD-10-CM guidelines. External cause codes may provide...

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