ED Coding and Reimbursement Alert

Question: A patient presented to the ED with the chief complaint of arm pain. The physician's final diagnosis is "possible supracondylar fracture." The doctor splinted the patient and referred him to an orthopedist for follow-up. The HPI notes a fall from a ladder that evening. The PE notes arm pain post fall, but nowhere in the dictation does it state "injury," "contusion," or "sprain." Should I report a code for injury, contusion, or sprain, or go with "arm pain" as the presenting complaint?

Maryland Subscriber

Answer: Because the fracture description includes the word "possible," your best bet is to code the arm pain. If the provider connected an abnormal x-ray to the possible fracture, you could also report 793.7 (Nonspecific abnormal findings on radiological and other examination of body structure; musculoskeletal system).
 
Also, you should report the appropriate E code to describe the fall from the ladder, because certain payers require it (E881.0). Even if you're submitting the claim to a payer that doesn't require an E code, having the additional description assists in creating a full picture for the insurance carrier as to why the patient needed emergency care.