Wiki Coding already reduced dislocation

[teebop6]

There is some debate as the appropriate way to code a dislocation that has already been reduced. Ex: Pt falls and dislocated their shoulder. They go to the ER and it is reduced there. They have a follow up visit at the Orthopaedic doctor's office (not the same one that did the reduction). Should it be coded as a dislocation? I think that the dislocation was reduce so that is not the current condition at the time of the E/M visit. I feel it should be a different dx. Code the current symptoms with a late effect of dislocation. Any advice on the appropriate way to code this?

 

[mitchellde]

There is some debate as the appropriate way to code a dislocation that has already been reduced. Ex: Pt falls and dislocated their shoulder. They go to the ER and it is reduced there. They have a follow up visit at the Orthopaedic doctor's office (not the same one that did the reduction). Should it be coded as a dislocation? I think that the dislocation was reduce so that is not the current condition at the time of the E/M visit. I feel it should be a different dx. Code the current symptoms with a late effect of dislocation. Any advice on the appropriate way to code this?

You are correct, once the dislocation has been reduced you cannot code it as a dislocation it is the same as a fracture, you use a V code such as V54.89 for other orthopedic aftercare or a V 67 code for follow up, you do not use the code for the dislocation at all.

 

[teebop6]

Thank you!