Wiki Shoulder Dislocation

[dkaz1]

Hi there:

I'm stumped!! Patient arrives with a shoulder dislocation suffered while sleeping and having a seizure. He states this has happened before and he with the help of a friend tried to reduce it at home before coming to the ED. The dislocation is reduced by a ortho doc who states recurrent shoulder dislocation as a dx.

My ED notes states shoulder pain as the encounter dx--the ED doctor states dislocation shoulder as a discharge diagnosis yet the ortho doc on his OP note states recurrent shoulder dislocation.

So, what dx code do I use?? 813.01 for a anterior dislocated shoulder with appropriate E codes OR 718.31 for a recurrent dislocated shoulder??

Please advise and thanks

 

[armen]

Hi there:

I'm stumped!! Patient arrives with a shoulder dislocation suffered while sleeping and having a seizure. He states this has happened before and he with the help of a friend tried to reduce it at home before coming to the ED. The dislocation is reduced by a ortho doc who states recurrent shoulder dislocation as a dx.

My ED notes states shoulder pain as the encounter dx--the ED doctor states dislocation shoulder as a discharge diagnosis yet the ortho doc on his OP note states recurrent shoulder dislocation.

So, what dx code do I use?? 813.01 for a anterior dislocated shoulder with appropriate E codes OR 718.31 for a recurrent dislocated shoulder??

Please advise and thanks

I think 718.31 would be correct.

 

[jimbo1231]

What about the seizure?

I'm also assuming there was some treatment/testing for the seizure. So don't forget there is probably an opportunity for a high E&M for the seizure depending on the work up that was done. And of course you will need an ICD-9 code and 25 mod to go with the E&M.

Jim

 

[Sueedwards]

If you are coding for the ER physician, I would code by his/her final diagnosis - and the ortho office will pick up his diagnosis for going into the ER.

 

[ivorytofu@hotmail.com]

If you are coding for the EDP then you would code the pain, the current dislocation of the shoulder, and then seizure. You will code to the appropriate E/M level for the EDP. Since the Ortho did the reduction you do not code that procedure.

831.??
719.41
780.39 or 345.90
then the E codes

As the ED coder coding the Pro --fee side you code what your EDP has in the HPI, Exam, and as a Dx.