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Code knee pain for injury of knee?

  1. Default Code knee pain for injury of knee?
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    I'm looking for guidelines or advice on the best code to pick up for a patient seen following a rollerblading incident. The provider chose "knee pain, 719.46," but I'm curious as to why he didn't choose an injury code.

    Subjective: Pt hurt his knee when he tripped and fell while rollerblading. It is very sore, but he can still walk.
    Exam: Left knee with bruise and mild swelling. Painful to palpation especially in the medial area.
    Assessment/Plan: Knee pain, 719.46 -- contusion and probable light strain vs sprain. Discussed icing and elevating. Note given to excuse from PE. Return if pain worsens or for any other concerns.

    How does one decide whether to code an injury or to code the symptoms? I realize the symptoms are not coded when a more definitive diagnosis is given, but here the provider chooses to code for pain, so I'm just confused. (I've been told by coworkers to go with what provider gives as his assessment as well as to realize they don't always give the best choice of codes, so okay to choose more appropriate ones when applicable.)

    I'm considering any/combo of these three:
    719.46: pain in joint, lower leg
    924.11: contusion of knee
    959.7: injury of knee

    Thank you!

  2. #2
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    Columbia, MO
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    12,892
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    Physicians do not always select correct codes so you code according to the note. The note specified contusion so that is what needs to be coded. The pain in knee is inherent to the contusion and is not coded. Had the provider specified the encounter was for pain control and that the pain is acute then you would use the 338 code for acute pain due to trauma in addition to the contusion. For this note however code only the contusion and the external cause code for the fall while rollerblading.

    Debra A. Mitchell, MSPH, CPC-H

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