Orthopedic Coding Alert

Question: We're coding for septic bursitis, but the documentation does not state the cause of infection. Should we choose from the bursitis diagnoses, or are there better choices?

Minnesota Subscriber

Answer: Yes, your best option is to turn to the bursitis diagnoses and code according to the treatment site. For example, you could report 726.33 (Olecranon bursitis) for elbow issues or 726.65 (Prepatellar bursitis) for knee problems. Also include 041.9 (Bacterial infection, unspecified) to explain the underlying problem.

Talk with your surgeon if her documentation doesn't state things clearly enough for coding purposes; she might need to include appended notes to the patient's file to support the best coding choice.