Wiki septic shoulder joint

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tag60

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Pt is seen in followup from rehab for shoulder. Exam shows "severely infected" left shoulder, with odor, draining pus. Assessment is "shoulder joint pain, septic left shoulder joint." Pt is advised to go to ER for debridement and IV antibiotics. No treatment or labs are ordered.

Doc has chosen 719.41 (shoulder pain) as diagnosis, but I'm wondering if I need to code more specifically to address "septic," or if there is really enough information (e.g., organism) provided in this short SOAP note.

In the index, Infection, joint, leads me to 711.01...but does this cover sepsis, or does a sepsis diagnosis require more workup? How would you code this? (Newbie here, still learning lots!)
 
The provider documented septic shoulder. Sepsis due to infection is 995.91 which requires an organism first listed. The guidelines specify that if no organism is documented then code 038.9 first listed with 995.91 secondary.
 
Do I need to provide any code that describes the location (shoulder)? I can't use "shoulder pain" as that is a symptom, correct?

Thank you for your help!
 
tag60 said:
Pt is seen in followup from rehab for shoulder. Exam shows "severely infected" left shoulder, with odor, draining pus. Assessment is "shoulder joint pain, septic left shoulder joint." Pt is advised to go to ER for debridement and IV antibiotics. No treatment or labs are ordered.

Doc has chosen 719.41 (shoulder pain) as diagnosis, but I'm wondering if I need to code more specifically to address "septic," or if there is really enough information (e.g., organism) provided in this short SOAP note.

In the index, Infection, joint, leads me to 711.01...but does this cover sepsis, or does a sepsis diagnosis require more workup? How would you code this? (Newbie here, still learning lots!)
Click to expand...

Sepsis always makes me cringe because of the reporting rules but 711.01 does cover your septic joint and I would use that more specific code than the generic shoulder pain. The pain won't cover the medical necessity for the IV antibiotics. Hopefully you will get others weighing in on this one. Good luck :)
 
711.01 is Pyogenic arthritis of the shoulder. In your post arthritis is not mentioned only that there is an infection that indicates a septic shoulder. So no 711.01 is not a good code. Given what you provider for information you follow the guidelines and code the sepsis. If the provider then indicates that the shoulder has developed a progenic arthritis due to the sepsis then you follow the guidelines for sepsis with a localized infection where the 038.9 is first listed, the 995.91 is secondary and the 711.01 is third.
 
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