Try Not to Overthink This Wrist Pain Case
Question: A 34-year-old patient presented to the radiology practice after falling on an outstretched hand. The patient was experiencing radial wrist pain and anatomic snuffbox tenderness. The radiologist captured posteroanterior (PA), lateral, oblique, and dedicated scaphoid X-ray views of the left wrist. The impression states no definitive acute fracture on the radiographs, and given the snuffbox tenderness, occult scaphoid fracture cannot be excluded. What diagnosis codes should I report? Missouri Subscriber Answer: Since the radiologist did not confirm a definitive injury following review of the X-ray images, you’ll need to assign a code that reflects the signs and symptoms the patient presented with. The ICD-10-CM Official Guidelines, Section I.B.4, signs and symptoms codes “are acceptable for reporting purposes when a related definitive diagnosis has not been established by the provider.” In this case, M25.532 (Pain in left wrist) accurately represents the patient’s signs. However, you’ll use a more specific diagnosis code if the radiologist performs additional imaging and then makes a definitive diagnosis after reviewing those images. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
