# Need help for a diagnosis of "Trauma. Pain."



## malissagiles (Feb 16, 2011)

Can someone respond who can support their recommendation on this question?

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 (shoulder, 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?


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## terribrown (Feb 16, 2011)

Section 1.B.6 in the coding guidelines reminds us that when a definitive diagnosis is not known, we must code symptoms. Depending on the entire information available, you could consider codes from trauma, pain or pain due to trauma categories.


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## malissagiles (Feb 16, 2011)

So for a lumbar x-ray with a diagnosis of "Trauma. Pain" with no findings, what is the ICD9 code you would use?

The documentation doesn't specify "lumbar pain" and since all the other reports also state "Trauma. Pain" we can't use common sense to assume that "Pain" in this case means "lumbar pain."

We also can't assume that the patient had a "lumbar trauma/injury" since all the other reports also state the same exact thing.

Thoughts?


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## preserene (Feb 16, 2011)

Could  this appropriate with your scenario?- V71.4 or V71.8 or V71.89 , 959.9.
The theme/ intend or the reason for the X-rays taken are suspected bony / Ligamentous injury following trauma not for pain (alone).
More over I do not find any diagnostic code correlating associated pain in trauma, it is a  part and parcel of a trauma/injury, though.
do I make any sense??!


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## terribrown (Feb 17, 2011)

There are two possible choices for pain due to trauma...but you need to know if it is acute or chronic. Go to 338.11 Pain, Acute, Due to trauma...or 338.21 Pain, Chronic, Due to trauma. Read these guidelines carefully. If you do not know acute or chronic, you cannot use this category. However, if no definitive diagnosis is given, these codes are permitted to be coded first. (Again we are coding symptoms when diagnosis is not known.)

If the record does not indicate acute or chronic, then consider 780.96 Pain (default code) AND 959.9 Trauma (default/unspecified code). Your CPT code will indicate location of the x-ray and therefore provide the third-party payer details about where the pain is.


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## terribrown (Feb 17, 2011)

One more thing to think about...you are concerned with the correct code when "no findings" are reported. Remember that pain is a symptom that will not show up on the x-ray anyway. By coding the symptom (pain) or cause of suspect (trauma unspecified), you are indicating that no proven, diagnosable cause has been found.


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