Wiki Coding Injuries w/ Negative X-rays

[ochichernye]

Hi everyone,

This one is really throwing me for a doozy.

So: a patient comes in and has had shoulder pain for 3 weeks because during a soccer game, the patient fell down after colliding with another player. 3 weeks later, an X-ray was done and it was negative. The physical exam didn't reveal any superficial injuries (contusions, abrasions, clicks, popping, etc.). There is tenderness along the spine and scapula. The patient was referred to PT.

My question is this: do we just code the shoulder pain (M25.512)? Or do we add the code for 'left shoulder injury, unspecified' (S40.912) in addition to the pain code even though the X-ray was negative? I chose the unspecified code because there are no abrasions, constrictions, blisters, foreign bodies, insect bites or other bites. There are no physical signs of the injury but we know the patient did fall down from running into somebody else.

Additionally, I have been told not to use external cause codes for this case because this patient's insurance usually doesn't accept them. Gah! Help!

 

[JenniferB7]

In the absence of a definitive diagnosis, you can bill the symptom code. In this case left shoulder pain (M25.512 is correct).

Adding the injury code would further help establish medical necessity (don't forget to add a 7th digit of A, D, or S), but S40.912A is also an external cause code. Unless I have something in writing from the payer (i.e., a reimbursement policy, medical policy, memo) advising that they do not want external cause codes on their claims, I would file the claim with the external cause codes to reflect an injury from falling down after colliding with another player while playing soccer. These codes would be secondary to the left shoulder pain above.

I know some practices choose not to bill the external cause codes because it can trigger an accident investigation to determine if another party is responsible for the claim, which delays payment. However, you don't want to misrepresent the diagnosis and have that discovered during an audit or retrospective review.

Hope that helps!

Jennifer M. Connell, BA, CPC, CENTC, CPCO

 

[SienTC1720]

I do lots of radiology coding for a hospital, especially for the ER, this one happens most often! The theme around here with those most often is "pain pays". As Jennifer stated, if there is no other diagnosis, we can use the symptom, and most insurances will accept them and pay!

 

[sheath]

...question

I do lots of radiology coding for a hospital, especially for the ER, this one happens most often! The theme around here with those most often is "pain pays". As Jennifer stated, if there is no other diagnosis, we can use the symptom, and most insurances will accept them and pay!

I code for hospital based radiologists and our coding team is split. "Unspecified injury of..." vs. "Encounter for observation of..." when no signs or sx are documented (requisition states "trauma") and there are no diagnostic findings.

Are there any articles or dx coding guidelines arguing against or in support of unspecified injury code assignment in this scenario?? If we were to assign an observation Z-Code in these instances we would get flooded with denials. Also due to our large volume of exams, reaching out to referring providers and/or hospital staff to request better documentation is not an option as far as my boss is concerned.

Any info would be greatly appreciated!

Happy Holidays

Stephanie Heath CPC