At odds with an answer

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I am working on a pactice test question from the AAPC for auditing. I was confused by one of the answers.

This is from the question, "25-year-old patient complains of an injury to her right shoulder leading to a probable dislocation that occurred 1 hour prior to arrival."

The documentation also says, "The patient reports a history of right shoulder dislocation in the past."

This is the correct ICD 10 code, according to the answer key "S43.014A."

But one of the answers is S43.014D. The difference between S43.014A and S43.014D is that "A" is for initial encounter and "D" is for subsequent encounter.

The documentation does not indicate how long ago the previous dislocation was. I read the previous dislocation and interpretted this visit to be a subsequent encounter, as if recently. So I picked S43.014D.

Is this a poorly worded question that would be worth quering the provider about to find out if this should be coded as S43.014D? Or is there a rule in coding to indicate that a hx is not a subsequent encounter unless it indicates recently being treated for the same condition?
 
Does it list the new dislocation as the official diagnosis for the encounter? If not, then I would disagree to coding a dislocation code at all because 1) it's marked as probable which means we can't code it and 2) even if the patient has a history of a dislocation, we wouldn't code that using the S43.014A/D. I agree this might be a poorly worded/documented test question.
 
This is the whole question, fyi. Excuse me if it's hard to read. The rational doesn't address the A/D issue that I had with the dislocation ICD-10 code S43.014.
The question and the correct answer and the rational I have posted to the top of this posting:
The question: 1. After review of the documentation provided and the codes selected, the correct ED E/M and ICD-10-CM codes are: (The correct answer: 99284, S43.014A, W20.8XXA. Y99.8, Y92.71)


Here is the rational:
Rational: 1:

The provider documents the following elements:


History: Comprehensive


Detailed HPI: Location, Duration, Context, Associated Signs and Symptoms
Comprehensive ROS: Musculoskeletal and All other systems reviewed and negative
Complete PSFH: Past and Social


Exam: Detailed


2-7 Extended body areas/organ systems examined: Constitutional, Head, Eyes, Neck, Cardiovascular (Heart), Respiratory (Lungs), Abdomen, Musculoskeletal, and Neurological


Medical Decision Making: Moderate


New problem to examiner; no further workup planned
One data point: X-ray
High level of risk: Parenteral controlled substance (Fentanyl 50 mg IV and Versed 2 mg IV)


Diagnosis is anterior dislocation of right shoulder (S43.014A). External cause codes the arm had twisted with hay falling on her in a barn (W20.8XXA, Y99.8, Y92.71).
End of Rational


The doctor's dictation:
Date of Service: 07/21/XX

Patient Name: A. Bey

Emergency Department Visit Note

Mode of arrival: Patient arrived via automobile. The patient’s condition upon arrival was stable.

Time seen by clinician: 1225

Chief Complaint: Right shoulder injury.

25-year-old patient complains of an injury to her right shoulder leading to a probable dislocation that occurred 1 hour prior to arrival. The patient states she was moving hay in the barn when she had her arm above her head and the hay fell back twisting her arm. The patient reports a history of right shoulder dislocation in the past. Patient has experienced mild numbness and tingling in the shoulder. Patient denies any further injury. No additional complaints or treatments prior to arrival.

Allergies: No Known Allergies

Patient’s Current Medications: Birth Control Pills

Review of Systems: All other systems reviewed and are negative.

PMH: As above.

Social History: Nonsmoker

Physical Exam: Vital Signs: T:98.1, P:97, B/P 168/85, O2 sat 95% room air. Alert. Head: Atraumatic, without temporal or scalp tenderness. Eyes: PERRL, EOMI, no discharge or injection. Neck: Supple, nontender. Lungs: Clear to auscultation and breath sounds equal, no wheezes, rales, or rhonchi. Heart: Regular rate and rhythm without murmurs, ectopy. Abdomen: No tenderness. Extremities: The right shoulder is tender with anterior dislocation deformity. Some mild swelling. Muscle strength and tone normal. No ecchymosis. Distal neurovascular status intact with capillary refill less than 2 seconds, distal pulses 2+, sensation to light touch present, grip strength 5/5. Neurological: Sensory and motor functions intact. Reflexes: Normal. DTRs normal, no pathologic reflexes.

Intervention:


I was notified of the X-ray results and will perform the reduction.

IV: Normal saline. Pulse Ox: 98% on room air X-ray right shoulder: Positive anterior dislocation. The patient was prepared and agreed to conscious sedation. Patient was monitored and included placement on continuous EKG monitoring, 02, suction and bag-valve-mask ready, pulse oximetry in place during the presence of Dr. Neam. Independent observation performed by Amy Smith, RN.



Fentanyl 50 mg IV and Versed 2 mg IV was given by me. The patient’s right shoulder was easily reduced using gentle traction. A sling was applied. Post reduction X-ray showed shoulder in good location with no obvious fracture. The patient tolerated the procedure very well. Total moderate conscious sedation time 20 minutes.
Diagnosis:

Anterior dislocation of right shoulder.

Discharge: The patient was discharged home accompanied by friend. The following prescriptions were given: Vicodin.

Follow-up with orthopedics in 4 to 5 days.

Return to ER if sxs worsen.

Signed by: J. Waters, MD

Emergency Department Fee Ticket

Patient NameA. Bey
Medical Record Number/Account Number0987652
ED PhysicianJ. Waters, MD
AnesthesiologistNone
Insurance CompanyUnited Healthcare
Comments

Date of SurgeryFacilityPlace of serviceCPT CodeDiagnosis Code(s)ModifierQuantity
Fee
07/21/20xxEast Regional
2399284S43.014A, W20.8XXA, Y99.8, Y92.71571$250.00
07/21/20xxEast Regional
2323650S43.014A, W20.8XXA, Y99.8, Y92.71541$350.00
07/21/20xxEast Regional2399152S43.014A, W20.8XXA, Y99.8, Y92.71 1$0.00








Total





$600.00
 
Ah ok yes - so it's definitely 7th character A because the patient is receiving active treatment. Examples of active treatment are surgery, an emergency department encounter, or evaluation and treatment by a new physician. The 7th character D is used during routine follow up. Hope that helps!

Thanks for posting all of that!
 
You're getting thrown off by the "probable dislocation" statement from when the patient presented to the ER.

The documentation clearly states that during the ER visit the patient was diagnosed with "Anterior dislocation of the right shoulder" - the ER physician even reduced the dislocation under conscious sedation.

The final character is A because the patient is being actively treated during the visit. The date of the previous dislocation is irrelevant here.

___________________________________________________

Diagnosis:

Anterior dislocation of right shoulder.

Discharge: The patient was discharged home accompanied by friend. The following prescriptions were given: Vicodin.

Follow-up with orthopedics in 4 to 5 days.

Return to ER if sxs worsen.

Signed by: J. Waters, MD
 
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