ED Coding and Reimbursement Alert

Question: A patient presented in the ED complaining of pain in his shoulder after a basketball game. The physician believed the patient sprained his rotator cuff, so I reported E927 (Overexertion). I then added -injured while playing basketball- to box 19. The carrier denied the claim, saying we didn't indicate the patient's injury. How should I resolve this?


Georgia Subscriber


Answer: The reason the insurer isn't reimbursing you is because technically, E927 doesn't describe an injury--you just use it to describe the external cause of the patient's injury. For the principal diagnosis, you should report a code that identifies the site of injury from the 800-999 series (Injury and poisoning).

In this case, 840.4 (Sprains and strains of shoulder and upper arm; rotator cuff [capsule]) may be appropriate, depending on the physician's documentation and whether the tear is complete. You should enter the diagnosis code describing the injury in box #21 of the CMS-1500 form. Reader Questions and You Be the Coder reviewed by Michael A. Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems Inc., an emergency department billing service in Stoneham, Mass.