Wiki Please help with DX coding

[twosmek]

Have a patient that had a partial excision of the clavicle and MD states that patient is having dysfunction because of the absent clavicle.

How would you code this??

This is the exact wording from the MD for the Dxes.

"Right shoulder impingement with scapular dyskinesia and some dysfunction because of the absent clavicle"

So I have

726.2 and 781.3

I was thinking of maybe using 736.89 other acquired deformities of other parts of limbs.

Suggestions would be greatly appreciated. Thanks

 

[mitchellde]

I am not having a problem with your choice of codes but I would also add a late effect code to show this is a late effect of either an injury or surgery. (905-909)

 

[twosmek]

only problem is that the MD did not know why the patient had the clavicle excision and the patient was a poor historian i guess, was done by another clinic and no notes. So if I did would I use an unspecified late effect 908.9?? or 909.9 completely unspecified as we have no idea if it was an injury or a disease that resulted in the excision.

 

[mitchellde]

In that case go with the 909.9. It may be important down the road that this be identified as a late effect.

 

[twosmek]

Thanks