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ED Coding and Reimbursement Alert

You Be the Coder

Published on Tue Feb 21, 2012

Question: How would you code the following scenario? A patient with a past medical history of shoulder dislocations comes to the ED due to a shoulder dislocation after stretching.Procedure note #1Consent: Verbal consent obtained.Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Time out: Yes Patient identity confirmed: Verbally with patient Injury location: shoulder Location details: right shoulder Injury type: dislocation Dislocation type: anterior with no Hill-Sachs deformity: no Chronicity: Pre-procedure neurovascular assessment: neurovascularly intact Pre-procedure distal perfusion: normal Pre-procedure neurological function: normal Pre-procedure range of motion: reduced Local anesthesia used: no Manipulation performed: yes Reduction method: scapular manipulation...not successfulProcedure note #2Consent: Verbal consent obtained.Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Time out: Yes Patient identity confirmed: Verbally with patient Injury location: shoulder Location details: right shoulder Injury type: dislocation Dislocation type: anterior with no Hill-Sachs deformity: no Chronicity: recurrent [...]
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