Diagnosis: Brainstem herniation
Procedure: Magnetic Resonance Imaging
(MRI), brainA 40- year -old male patient was brought to the emergency department (ED) via ambulance after he fell at home and hit his head on the edge of the bathtub at home. His wife stated that he was unconscious for an undetermined amount of time when she found him. The ED physician provided a level 4 service and noted that the patient scored a 9 on the Glasgow Coma Scale. An initial dose of 50 mg of phenytoin was administered via slow intravenous (IV) push. The physician also ordered an MRI, which revealed a brainstem herniation.
Instructions: Assign ICD-10-CM, CPT, and HCPCS level II codes for this case, including ICD-10-CM external cause codes.

ICD-10-CM: ____, ____, ____
CPT: ____, ____, ____
HCPCS Level II: ____