Wiki Coding Injuries w/ Negative X-rays

[ochichernye]

Hi everyone,

This one is really throwing me for a doozy.

So: a patient comes in and has had shoulder pain for 3 weeks because during a soccer game, the patient fell down after colliding with another player. 3 weeks later, an X-ray was done and it was negative. The physical exam didn't reveal any superficial injuries (contusions, abrasions, clicks, popping, etc.). There is tenderness along the spine and scapula. The patient was referred to PT.

My question is this: do we just code the shoulder pain (M25.512)? Or do we add the code for 'left shoulder injury, unspecified' (S40.912) in addition to the pain code even though the X-ray was negative? I chose the unspecified code because there are no abrasions, constrictions, blisters, foreign bodies, insect bites or other bites. There are no physical signs of the injury but we know the patient did fall down from running into somebody else.

Additionally, I have been told not to use external cause codes for this case because this patient's insurance usually doesn't accept them. Gah! Help!

 

[JenniferB7]

In the absence of a definitive diagnosis, you can bill the symptom code. In this case left shoulder pain (M25.512 is correct).

Adding the injury code would further help establish medical necessity (don't forget to add a 7th digit of A, D, or S), but S40.912A is also an external cause code. Unless I have something in writing from the payer (i.e., a reimbursement policy, medical policy, memo) advising that they do not want external cause codes on their claims, I would file the claim with the external cause codes to reflect an injury from falling down after colliding with another player while playing soccer. These codes would be secondary to the left shoulder pain above.

I know some practices choose not to bill the external cause codes because it can trigger an accident investigation to determine if another party is responsible for the claim, which delays payment. However, you don't want to misrepresent the diagnosis and have that discovered during an audit or retrospective review.

Hope that helps!

Jennifer M. Connell, BA, CPC, CENTC, CPCO

 

[SienTC1720]

I do lots of radiology coding for a hospital, especially for the ER, this one happens most often! The theme around here with those most often is "pain pays". As Jennifer stated, if there is no other diagnosis, we can use the symptom, and most insurances will accept them and pay!

 

[sheath]

...question

I do lots of radiology coding for a hospital, especially for the ER, this one happens most often! The theme around here with those most often is "pain pays". As Jennifer stated, if there is no other diagnosis, we can use the symptom, and most insurances will accept them and pay!

I code for hospital based radiologists and our coding team is split. "Unspecified injury of..." vs. "Encounter for observation of..." when no signs or sx are documented (requisition states "trauma") and there are no diagnostic findings.

Are there any articles or dx coding guidelines arguing against or in support of unspecified injury code assignment in this scenario?? If we were to assign an observation Z-Code in these instances we would get flooded with denials. Also due to our large volume of exams, reaching out to referring providers and/or hospital staff to request better documentation is not an option as far as my boss is concerned.

Any info would be greatly appreciated!

Happy Holidays

Stephanie Heath CPC

 

[mshorey]

Hi everyone,

This one is really throwing me for a doozy.

So: a patient comes in and has had shoulder pain for 3 weeks because during a soccer game, the patient fell down after colliding with another player. 3 weeks later, an X-ray was done and it was negative. The physical exam didn't reveal any superficial injuries (contusions, abrasions, clicks, popping, etc.). There is tenderness along the spine and scapula. The patient was referred to PT.

My question is this: do we just code the shoulder pain (M25.512)? Or do we add the code for 'left shoulder injury, unspecified' (S40.912) in addition to the pain code even though the X-ray was negative? I chose the unspecified code because there are no abrasions, constrictions, blisters, foreign bodies, insect bites or other bites. There are no physical signs of the injury but we know the patient did fall down from running into somebody else.

Additionally, I have been told not to use external cause codes for this case because this patient's insurance usually doesn't accept them. Gah! Help!

reat question! Let's break it down:

1. Shoulder Pain (M25.512):
   The most appropriate primary diagnosis code in this case is M25.512 for shoulder pain. The patient has been experiencing pain for 3 weeks after the fall, and pain is the primary complaint, regardless of the negative X-ray results. The X-ray being negative doesn’t rule out an injury or other underlying issue; it just means no fractures or dislocations were detected.
2. Left Shoulder Injury, Unspecified (S40.912):
   You might be tempted to use S40.912, but given the specifics in the case (no visible signs of injury, no definitive diagnosis from the physical exam or imaging), this code may not be appropriate. The unspecified injury code is typically used for situations where there is a clear injury but no further information about the injury’s severity or nature. However, in this case, we don’t have a confirmed injury—just pain that’s likely due to trauma (the fall).
   Key point: The unspecified injury code should generally be reserved for cases where there is a known injury (but unspecified details), not for cases where the injury is unclear or undiagnosed.
3. Coding for Pain:
   Since the patient’s primary complaint is pain (M25.512), and there is no definitive injury identified, it is sufficient to code the pain without using an additional unspecified injury code.
4. External Cause Codes:
   As you mentioned, if the patient's insurance doesn’t accept external cause codes, you should follow the insurance guidelines and refrain from using them. External cause codes are helpful for documenting the nature of the accident (e.g., fall due to collision during a soccer game), but if they’re not accepted by the insurer, it’s best to omit them.

Final Answer:​

• Primary Diagnosis: M25.512 (shoulder pain)
• No need for S40.912 because there is no specific injury identified, and this would be redundant.
• Do not use external cause codes if the insurance does not accept them.

So, you should only use M25.512 and not add the unspecified injury code, and skip external cause codes due to the insurance guidelines.