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New
Hello fellow coding gurus - Looking for any insight on why we would be getting a denial of 20611 for a 71 yo patient with history of fall (>6 months prior) previous xray and MRI done by another treating entity -grade 3 dislocation of the AC joint presenting now to us as a NEW patient with pain/effusion and "bump" in his shoulder. The denial indicates per Medicare coding/payment standards - the aspiration/arthrocentesis/injection of a major joint/bursa code is incorrect without a MAJOR JOINT related diagnosis. The codes submitted were: M25.411, M25.511 and S43.131S. I have considered the heirachy of how codes were listed? Is the "sequela" designation not appropriate? Thank you for any feedback.
CHIEF COMPLAINT
Right shoulder injury.
HISTORY OF PRESENT ILLNESS
XXXX is a pleasant 71-year-old gentleman, who presents to clinic today for chronic right shoulder problem ever since he fell off a bike in July of last year and he landed directly onto his right shoulder. He had immediate pain, swelling and bruising. It has been persistently uncomfortable. He noticed a bump over his lateral shoulder. He has pain with crossing his arm to the other side of his body, as well as lifting overhead. It is relieved with rest. He has difficulty sleeping. He recently saw his primary care physician in early February and x-rays and MRI were ordered and he is here today for followup. He has tried over-the-counter medication with mild relief. He endorses pain with activity. It is relieved with rest. Denies numbness or tingling. No further complaints. No prior surgery in the right shoulder.
Past medical history, past surgical history, medications, allergies, social history, family history, review of systems were all reviewed and appropriately documented in the intake form. Of note, he recently had hernia surgery. He is retired. He states he quit smoking and drinking alcohol.
EXAMINATION:
Alert and oriented, in no acute distress. Normal affect. Examination of the right shoulder reveals a palpable bump and abnormality over the AC joint. There is point tenderness in this area. He has pain with cross body adduction, as well as forward elevation, but he has reasonable full range of motion. He has good strength throughout rotator cuff testing. He is neurovascularly intact.
IMAGING
Outside x-rays and MRI of the right shoulder were reviewed. This reveals in summary a right shoulder AC separation type 3.
ASSESSMENT
A chronic right shoulder acromioclavicular joint separation.
PLAN
Diagnosis and treatment options were discussed with XXXX I did not believe surgical option will be warranted at this time. I will recommend activity modification, over-the-counter medicines and potentially a cortisone injection. He would like to try the shot today.
The right shoulder was evaluated with a straight ultrasound probe. We identified the AC joint for which we able to identify the separation. There was an effusion in the joint and under sterile preparation, ultrasound guidance and a short-axis technique, we performed a right shoulder acromioclavicular joint injection with 1 mL of 1% lidocaine and 1 mL of 40 mg Kenalog. Single vial used, no waste. Ultrasound images were saved and permanently recorded in the PACS system. The patient tolerated the injection well. Post-injection instructions provided. He will follow up in 3 to 4 months as needed or if he would like to repeat a cortisone shot or see me back as needed.
CHIEF COMPLAINT
Right shoulder injury.
HISTORY OF PRESENT ILLNESS
XXXX is a pleasant 71-year-old gentleman, who presents to clinic today for chronic right shoulder problem ever since he fell off a bike in July of last year and he landed directly onto his right shoulder. He had immediate pain, swelling and bruising. It has been persistently uncomfortable. He noticed a bump over his lateral shoulder. He has pain with crossing his arm to the other side of his body, as well as lifting overhead. It is relieved with rest. He has difficulty sleeping. He recently saw his primary care physician in early February and x-rays and MRI were ordered and he is here today for followup. He has tried over-the-counter medication with mild relief. He endorses pain with activity. It is relieved with rest. Denies numbness or tingling. No further complaints. No prior surgery in the right shoulder.
Past medical history, past surgical history, medications, allergies, social history, family history, review of systems were all reviewed and appropriately documented in the intake form. Of note, he recently had hernia surgery. He is retired. He states he quit smoking and drinking alcohol.
EXAMINATION:
Alert and oriented, in no acute distress. Normal affect. Examination of the right shoulder reveals a palpable bump and abnormality over the AC joint. There is point tenderness in this area. He has pain with cross body adduction, as well as forward elevation, but he has reasonable full range of motion. He has good strength throughout rotator cuff testing. He is neurovascularly intact.
IMAGING
Outside x-rays and MRI of the right shoulder were reviewed. This reveals in summary a right shoulder AC separation type 3.
ASSESSMENT
A chronic right shoulder acromioclavicular joint separation.
PLAN
Diagnosis and treatment options were discussed with XXXX I did not believe surgical option will be warranted at this time. I will recommend activity modification, over-the-counter medicines and potentially a cortisone injection. He would like to try the shot today.
The right shoulder was evaluated with a straight ultrasound probe. We identified the AC joint for which we able to identify the separation. There was an effusion in the joint and under sterile preparation, ultrasound guidance and a short-axis technique, we performed a right shoulder acromioclavicular joint injection with 1 mL of 1% lidocaine and 1 mL of 40 mg Kenalog. Single vial used, no waste. Ultrasound images were saved and permanently recorded in the PACS system. The patient tolerated the injection well. Post-injection instructions provided. He will follow up in 3 to 4 months as needed or if he would like to repeat a cortisone shot or see me back as needed.