Good day all,
I have a bit of a sticky situation with my Plastics Dr. She tends to do a fair number of breast reductions, and she'll do whatever she can to get them covered by insurance. Great for the patient. Not so great for me when she starts listing off her Diagnosis. Among other things, she will quite often have 'Shoulder Lesion, bilateral' in there. Along with 'Shoulder pain (right or left)'.
The only problem with this from the coding perspective (which I tried to explain to her), is that going Lesion> Shoulder in the index lands me squarely in the musculoskeletal chapter. So that effectively nixes the shoulder pain.
When I asked her about it, I got a reply to the effect of 'That's to describe the shoulder grooving. It's standard documentation for this sort of issue/procedure we'd like to do."
Good for her. But the way she's wording things still leads me off into The Land of Muscles and Pain. Does anyone have any suggestions for alternative codes? I don't know that I'm going to be successful in suggesting she phrase things differently (or if I even should). She IS mentioning shoulder grooving up in the HPI when the patient lists off the problems she's got. I know it's there. I just can't seem to come up with a code to describe it appropriately.
Thanks!
I have a bit of a sticky situation with my Plastics Dr. She tends to do a fair number of breast reductions, and she'll do whatever she can to get them covered by insurance. Great for the patient. Not so great for me when she starts listing off her Diagnosis. Among other things, she will quite often have 'Shoulder Lesion, bilateral' in there. Along with 'Shoulder pain (right or left)'.
The only problem with this from the coding perspective (which I tried to explain to her), is that going Lesion> Shoulder in the index lands me squarely in the musculoskeletal chapter. So that effectively nixes the shoulder pain.
When I asked her about it, I got a reply to the effect of 'That's to describe the shoulder grooving. It's standard documentation for this sort of issue/procedure we'd like to do."
Good for her. But the way she's wording things still leads me off into The Land of Muscles and Pain. Does anyone have any suggestions for alternative codes? I don't know that I'm going to be successful in suggesting she phrase things differently (or if I even should). She IS mentioning shoulder grooving up in the HPI when the patient lists off the problems she's got. I know it's there. I just can't seem to come up with a code to describe it appropriately.
Thanks!