ED Coding and Reimbursement Alert

Question: How would you code the following scenario? A patient with a past medical history of shoulder dislocations comes to the ED due to a shoulder dislocation after stretching.

Consent: Verbal consent obtained.

Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Time out: Yes Patient identity confirmed: Verbally with patient Injury location: shoulder Location details: right shoulder Injury type: dislocation Dislocation type: anterior with no Hill-Sachs deformity: no Chronicity: Pre-procedure neurovascular assessment: neurovascularly intact Pre-procedure distal perfusion: normal Pre-procedure neurological function: normal Pre-procedure range of motion: reduced Local anesthesia used: no Manipulation performed: yes Reduction method: scapular manipulation...not successful

Consent: Verbal consent obtained.

Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Time out: Yes Patient identity confirmed: Verbally with patient Injury location: shoulder Location details: right shoulder Injury type: dislocation Dislocation type: anterior with no Hill-Sachs deformity: no Chronicity: recurrent Pre-procedure neurovascular assessment: neurovascularly intact Pre-procedure range of motion: reduced Local anesthesia used: no Manipulation performed: yes Reduction method: FARES technique....successful

Reduction successful: yes

Recurrent shoulder dislocation. Decreased ROM, obvious deformity. Neurovascularly intact. X-ray shows anteromedial dislocation.

7:47 AM attempted reduction using scapular manipulation. See note. Felt go in, patient still complaining of pain afterwards. ROM improved. Will x-ray.

8:15 AM x-ray shows continued dislocation. Re-manipulated, pain/ROM improved, placed in sling. Will x-ray again.

8:58 AM as x-ray came to visit, patient states that she reached for her phone and felt her shoulder go out again. Used FARES (Fast, Reliable, Safe) technique, shoulder reduced once again. Placed in sling. Will x-ray.

X-ray shows reduced shoulder. Patient remains neurovascularly intact. Patient placed in immobilizer. Told to remain in immobilizer for 1 week and follow up with ortho at that time. The patient's symptoms have improved. The patient does not appear to have an emergent issue at this time, and vital signs are stable. The patient was told to follow up with her PCP for further medical management and to return to the ED if symptoms worsen. The patient agrees with plan.

Answer: This is an interesting case because the dislocation was reduced multiple times before it successfully remained in place. Many groups chose not to report unsuccessful procedures or for failed attempts when it takes multiple tries to obtain the desired results.

Report 23650 (Closed treatment of shoulder dislocation, with manipulation; without anesthesia) along with 99284-25 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: detailed focused history; detailed examination; and medical decision making of moderate complexity...) for the E/M service as supported by the ED course notes in addition to the procedure.

Although several x-rays are referenced, the chart documentation does not satisfy the level of separately identifiable report to justify reporting them separately.

Add diagnosis code 831.01 (Closed dislocation, shoulder, anterior dislocation of humerus)