Primary Care Coding Alert

Question: Our FP treated a patient who had been in a minor motorcycle accident (the patient was the passenger, and the motorcycle hit a car while traveling at a low speed). The patient complained of jaw pain, and the notes indicate a diagnosis of mandibular deviation. What diagnosis code(s) do I need to include? Is this injury considered an abnormal jaw closure?

Minnesota Subscriber

Answer: Not exactly. When a patient has difficulty chewing or biting food, he may have an abnormal jaw closure, which you would represent with M26.51 (Abnormal jaw closure). Based on the notes you describe, however, there is a more specific diagnosis code for the patient. Because the physician documented “mandibular deviation,” the better diagnosis for this patient would be M26.53 (Deviation in opening and closing of the mandible).

Remember: In addition to M26.53, report V23.5- (Motorcycle passenger injured in collision with car, pick-up truck or van in traffic accident) to represent the cause of the patient’s injuries, being sure to add two X placeholders along with the appropriate seventh character A, D, or S to indicate whether the encounter with your provider was the initial encounter, a subsequent encounter, or for treating sequela to the injury. For instance, if this was the initial encounter, the causal code would be V23.5XXA.