Hi,
This is a time-sensitive question since I am being pressured by upper management to use the laterality specific dx. The provider has mentioned in his notes "Pain in shoulder, unspecified laterality". Patient is having a left shoulder x-ray performed. I am being told that the dx to be used should be "left shoulder pain". From what I know, the provider should be queried and the note amended. Please let me know if I am wrong. I used unspecified shoulder pain dx since there was no way for me to contact the provider but I am being told to just assume the laterality. I want to reach out to the upper management but would love some concrete input from the seasoned coders.
Thank you so much!
This is a time-sensitive question since I am being pressured by upper management to use the laterality specific dx. The provider has mentioned in his notes "Pain in shoulder, unspecified laterality". Patient is having a left shoulder x-ray performed. I am being told that the dx to be used should be "left shoulder pain". From what I know, the provider should be queried and the note amended. Please let me know if I am wrong. I used unspecified shoulder pain dx since there was no way for me to contact the provider but I am being told to just assume the laterality. I want to reach out to the upper management but would love some concrete input from the seasoned coders.
Thank you so much!