I'm looking for guidelines or advice on the best code to pick up for a patient seen following a rollerblading incident. The provider chose "knee pain, 719.46," but I'm curious as to why he didn't choose an injury code.
Subjective: Pt hurt his knee when he tripped and fell while rollerblading. It is very sore, but he can still walk.
Exam: Left knee with bruise and mild swelling. Painful to palpation especially in the medial area.
Assessment/Plan: Knee pain, 719.46 -- contusion and probable light strain vs sprain. Discussed icing and elevating. Note given to excuse from PE. Return if pain worsens or for any other concerns.
How does one decide whether to code an injury or to code the symptoms? I realize the symptoms are not coded when a more definitive diagnosis is given, but here the provider chooses to code for pain, so I'm just confused. (I've been told by coworkers to go with what provider gives as his assessment as well as to realize they don't always give the best choice of codes, so okay to choose more appropriate ones when applicable.)
I'm considering any/combo of these three:
719.46: pain in joint, lower leg
924.11: contusion of knee
959.7: injury of knee
Thank you!
Subjective: Pt hurt his knee when he tripped and fell while rollerblading. It is very sore, but he can still walk.
Exam: Left knee with bruise and mild swelling. Painful to palpation especially in the medial area.
Assessment/Plan: Knee pain, 719.46 -- contusion and probable light strain vs sprain. Discussed icing and elevating. Note given to excuse from PE. Return if pain worsens or for any other concerns.
How does one decide whether to code an injury or to code the symptoms? I realize the symptoms are not coded when a more definitive diagnosis is given, but here the provider chooses to code for pain, so I'm just confused. (I've been told by coworkers to go with what provider gives as his assessment as well as to realize they don't always give the best choice of codes, so okay to choose more appropriate ones when applicable.)
I'm considering any/combo of these three:
719.46: pain in joint, lower leg
924.11: contusion of knee
959.7: injury of knee
Thank you!