Orthopedic Coding Alert
Don’t Throw in the Towel When Presented With Tough Discitis Dx
Question: Encounter notes indicate that the patient suffered from “discitis.” That’s all I have; no mention of type, anatomical location, etc. What should I do? New Mexico Subscriber Answer: The ideal course of action would be to contact the performing provider and ask them for the information you need regarding the discitis diagnosis. That isn’t always possible, however. So, if you cannot get the info you need from the provider, report M46.40 (Discitis, unspecified, site unspecified). That’s about as specific as you can get with this wafer-thin encounter note. 1 more option: You might be able to uncover at least the anatomical location of the discitis via the encounter notes. That would make the diagnosis more specific, if not dead-on. If you do figure out the anatomical location of the discitis — but not the type — choose from the following codes: 
Orthopedic Coding Alert
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Don’t Throw in the Towel When Presented With Tough Discitis Dx
Question: Encounter notes indicate that the patient suffered from “discitis.” That’s all I have; no [...]
