Help with diagnosis

Can I have someone who can support their recommendation comment on this.

I need the diagnosis for this lumbar x-ray, there were no findings, it was a normal L-spine. The reason for the exam is documented as "Trauma. Pain."

The patient had other films done that day (shouler, arm, hip, t-spine, etc) and the reason on all of them was "Trauma. Pain."

All the studies were normal except for the arm x-ray which showed a humeral fracture.

How would the exams that said "Trauma. Pain." be coded when there were no findings?

Thanks, Jen

Trauma,pain

I usually use contusion, then the cooresponding body part for these cases.

Diagnosis for "Trauma. Pain."

Contusion definitely isn't documented.

What diagnosis code would you use on the following exams? They are all for the same patient, same day.

Lumbar 2 Views

Reason: Trauma. Pain.

Impression: normal spine.

Shoulder 2 views

Reason: Trauma. Pain.

Impression: Normal shoulder, however can see humeral fracture on film.

Chest 1 view

Reason: Trauma. Pain.

Impression: Normal chest.

Thoracic 2 views

Reason: Trauma. Pain.

Impression: normal spine.

Humerus 2 views

Reason: Trauma. Pain.

Impression: Humeral shaft fracture – this one is easy, 812.21

What diagnosis code would you use on the following exams? They are all for the same patient, same day.

Why not code for the pain? I would use 724.1(thoracic spine pain), 724.2(lumbar region pain), and 719.41(shoulder pain).

trauma, pain dx codes

I'm sorry, I meant to say injury by site. If you look up the word trauma in the ICD-9, it tells you to see injury by site. However if there is any documentation of traumatic ecchymosis, you would use contusion by site. (see ecchymosis in ICD-9) Hope this helps some.
injury codes are back-959.19; shoulder- 959.2; chest- 959.11; elbow - 959.3

pain

i would ask the doc who ordered the x-rays to be more specific! they don't realize how miserable they can make a coder. i don't assume anything not documented.

But I was taught

for xrays better to put the symptom and let the radiologist pick the diagnosis- you prefer that to me guessing what you will find. So if I put fracture and there is not one, then you have a harder time coding it. So I put finger injury.