Bernadette10
Guru
Patient is being seen for the first time in the ortho clinic for a left greater tuberosity fracture with associated shoulder dislocation.
Patient states that he was walking when his knee buckled, causing him to fall onto his left shoulder. He had immediate pain and deformity and went to the ED where he underwent closed reduction of his shoulder dislocation. He was placed in a sling and is presenting for followup. States that since then his pain has improved. Endorses tingling in his left shoulder. Currently has no complaints.
How would this diagnosis be coded? S42.252A fracture of greater tuberosity of LT humerus, BUT would the dislocation also be coded, even though it was previously reduced in the ER? And would it be S43.005A initial encounter since this is the first time the patient is being seen for it by a new provider, or S43.005D since it was already reduced?
The plan was to keep him in the sling and have him come back in a couple weeks to see how it was healing, so they didn't really address the dislocation, so maybe it wouldn't be coded, but since it caused the fracture, maybe it should be coded? Just not sure on this. Thanks for any help.
Patient states that he was walking when his knee buckled, causing him to fall onto his left shoulder. He had immediate pain and deformity and went to the ED where he underwent closed reduction of his shoulder dislocation. He was placed in a sling and is presenting for followup. States that since then his pain has improved. Endorses tingling in his left shoulder. Currently has no complaints.
How would this diagnosis be coded? S42.252A fracture of greater tuberosity of LT humerus, BUT would the dislocation also be coded, even though it was previously reduced in the ER? And would it be S43.005A initial encounter since this is the first time the patient is being seen for it by a new provider, or S43.005D since it was already reduced?
The plan was to keep him in the sling and have him come back in a couple weeks to see how it was healing, so they didn't really address the dislocation, so maybe it wouldn't be coded, but since it caused the fracture, maybe it should be coded? Just not sure on this. Thanks for any help.