Forum - Questions & Answers

Feb 16th, 2011 - jschmutz   323 

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

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Feb 17th, 2011 - EVALAPPIN 7 

Trauma,pain

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

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Feb 17th, 2011 - jschmutz   323 

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

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Feb 17th, 2011 -

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).

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Feb 17th, 2011 - EVALAPPIN 7 

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

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Mar 11th, 2011 - HIMcoder 41 

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.

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Mar 13th, 2011 -

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.

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