ED Coding and Reimbursement Alert

Question: A patient with Group A hyperlipidemia (hypercholesterolemia) arrives at the ED with a dislocated shoulder she injured while driving a personal watercraft in the ocean. An x-ray reveals a fracture of the greater tuberosity. The physician treats the shoulder with manipulation. Should I include ICD-9 codes for her chronic condition on the claim?


California Subscriber


Answer: It depends on the operative notes and the physician's course of treatment. If the doctor confirms that the patient's cholesterol level wasn't relevant to the treatment of the shoulder, you should:

- report 23665 (Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation) for the shoulder repair.

- attach ICD-9 code 831.xx (Dislocation of shoulder) to 23665 to show the reason for the procedure.

- attach E831.2 (Accident to watercraft causing other injury; occupant of other watercraft -- crew) to show that an accident caused the patient's injury.

Exception: If the patient's hypercholesterolemia affects the physician's choice of treatment options, you will want to report an ICD-9 code for the chronic condition. For instance, the patient's cholesterol may limit or change medication choices for the physician as he treats the shoulder injury.
 
In the above example, if the physician decided for or against a certain medication because of the patient's hypercholesterolemia, you should:

- report 23665 for the shoulder repair.
- attach 831.xx to 23665 to show the reason for the procedure.
- attach 272.0 (Pure hypercholesterolemia) to 23665 to represent the patient's chronic condition.
- attach E831.2 to show that an accident caused the patient's injury.