Anesthesia Coding Alert

Question: A young woman had an accident while skiing that led to her left shoulder being dislocated and fractured. It had impact on the medial condyle and left distal humerus. The orthopedic surgeon operated on her shoulder without directly visualizing the injured site. How do we code the anesthesia and diagnosis?

Ohio Subscriber

Answer: Keep in mind that your procedure coding should report the management or approach of the treatment and the location of the fracture; your diagnosis code will reflect the location along with the severity of the fracture and whether there are any complications due to fracture. Once you know all this information, you can pinpoint the associated anesthesia code.

Because the orthopedic surgeon in this case performed the surgery without seeing the fracture site, this is considered a closed treatment. The correct surgical code would be 23665-LT (Closed treatment of shoulder dislocation with fracture of greater humeral tuberosity, with manipulation; requiring anesthesia; Left side). This crosses to anesthesia code 01620 (Anesthesia for all closed procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint), which carries a base unit value of four.

Your ICD-10 diagnosis selections should be S42.442A (Displaced fracture [avulsion] of medial epicondyle of left humerus, initial encounter for closed fracture) and Y93.23 (Activity, snow [alpine] [downhill] skiing, snowboarding, sledding, tobogganing and snow tubing).