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Shoulder Dislocation

  1. #1
    Default Shoulder Dislocation
    Medical Coding Books
    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

  2. #2
    Default
    Quote Originally Posted by dkaz1 View Post
    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.

  3. Default 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

  4. #4
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    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.
    Susan Edwards, CPC, CEDC
    smecoder@gmail.com

  5. Default
    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.

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