ED Coding and Reimbursement Alert

Question: A patient presented in the ED complaining of pain in his shoulder after a basketball game. The physician believed the patient sprained his rotator cuff, so I reported E927 (Overexertion and strenuous movements). I then added "injured while playing basketball" to box 19. The carrier denied the claim, saying we didn't indicate the patient's injury. How should I resolve this?

Georgia Subscriber

Answer: The reason the insurer isn't reimbursing you is because technically, E927 doesn't describe an injury -- you just use it to describe the external cause of the patient's injury. Additionally E927 relates to overexertion and to repetitive movement, which may not accurately describe a basketball injury. It is not the best choice. You might have considered instead E007.6 (Activities involving other sports and athletics played as a team or group, basketball).

For the principal diagnosis, you should report a code that identifies the site of injury from the 800-999 series (Injury and poisoning). In this case, 840.4 (Sprains and strains of shoulder and upper arm; rotator cuff [capsule]) may be appropriate, depending on the physician's documentation and whether the tear is complete. The diagnosis code describing the injury should be reported in box #21 of the 1500 form.