How to code the case1. A Constance Williams came into the office with the following complaints: abdominal pain in the left upper quadrant and exhibits blurred vision and nausea after being involved in a car/ truck wreck. The patient states while traveling south on the 110 freeway a large cargo truck struck him head on, causing him to be thrown back and forward forcibly striking his chest/rib area against the steering wheel. He states that the impact was so hard and painful he actually broke the rear-view mirror off. The patient was brought to the emergency room today by ambulance. The course of treatment - due to chest pain a chest x-ray was ordered along with an EKG. The Emergency physician consulted the surgeon on call to evaluate the patient. After a 45 minute to 60-minute examination the surgeon makes a decision to perform an exploratory laparotomy to determine if the spleen and a portion of the small intestine are injured. Noting extensive splenic tears, the surgeon proceeds to bluntly dissect the spleen and remove it, ligating gastric arteries and clamping the splenic pedicle to control bleeding. Code the Case