Let us go through this scenario one step at a time. The patient presented to the ER after a fall with his left shoulder injury and found to have a closed, (probably and most commonly) anterior dislocation of the shoulder, and a closed, displaced fracture of the Greater Tuberosity. (This fracture in this combination injury is usually displaced, and without any information to indicate otherwise would be deemed displaced by Default.) Since this is the Initial Encounter for both injuries/diagnoses, the 7th Character would be A. This gives the 2 diagnoses code of S43.015A for the Dislocation, and S42.252A for the Tuberosity Fracture. In the ER the patient underwent a Closed Reduction of the Dislocation, which in fact and coincidentally was also a Closed Manipulative Reduction of the Greater Tuberosity Fracture. After that the patient was placed in a Sling or Immobilizer as the post-reduction treatment plan. The patient was discharged from the ER and referred to your Orthopedic Surgeon for follow up evaluation and care of both injuries/diagnoses.
After evaluating the patient in your clinic, your physician accepted the post-reduction status of both injuries, particularly the alignment of the Greater Tuberosity Fracture. He did not recommend any other additional evaluation or studies such as an CT Scan or MRI, which would have kept the patient in the Active Evaluation and Treatment Status (7th Character A) as the results of these studies might have changed the future treatment of the patient, most likely Open Surgical Treatment of the Greater Tuberosity Fracture if found to be too displaced to be acceptable for continued closed treatment.. He did not alter or change the Treatment Plan established in the ER after the reduction, i.e. the plan of Rest and Immobilization. With this in mind, both diagnoses need to be listed as your physician is providing follow up care for both, but the 7th Characters would change to D since nothing was changed.
Hopefully this is clear and helpful.
Respectfully submitted, Alan Pechacek, M.D.
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