Question Xray diagnosis fall vs early degeneration

mcrossley

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A patient had a knee xray performed due to pain from a fall (work injury) and the impression mentions early djd and joint effusion. It was charged out with M17.11. Is this correct or should it have been coded with the injury/effusion?
 

thomas7331

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There is no injury documented here, so you can't use an injury code. I think you could justify using knee pain with the external cause code for the fall since those were the reasons for the x-ray and the provider has not indicated whether the pain is due to the DJD and effusion or from some other source that was not determined by the x-ray. In that case, I would use the DJD and effusion diagnoses as secondary codes for the incidental findings.
 
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