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 Name | A. Bey
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Medical Record Number/Account Number | 0987652 |
ED Physician | J. Waters, MD |
Anesthesiologist | None |
Insurance Company | United Healthcare |
Comments |
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Date of Surgery | Facility | Place of service | CPT Code | Diagnosis Code(s) | Modifier | Quantity
| Fee |
07/21/20xx | East Regional
| 23 | 99284 | S43.014A, W20.8XXA, Y99.8, Y92.71 | 57 | 1 | $250.00 |
07/21/20xx | East Regional
| 23 | 23650 | S43.014A, W20.8XXA, Y99.8, Y92.71 | 54 | 1 | $350.00 |
07/21/20xx | East Regional | 23 | 99152 | S43.014A, W20.8XXA, Y99.8, Y92.71 | | 1 | $0.00 |
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Total |
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| $600.00 |