If this is a Shoulder Labral Tear this article should help:
http://codingnews.inhealthcare.com/hot-coding-topics/orthopedic-coding-clinic-labral-tears/
Orthopedic Coding Clinic: Labral Tears
Posted on 28. Jan, 2010 by in Hot Coding Topics
10-2:00 in the op note signals SLAP lesion repair.
Even experts can land on the wrong ICD-9 code for SLAP lesion repair, but visualizing the injury region as a clock will help you distinguish one type of SLAP (superior labral anterior posterior) tear from another.
Research Patient History for Accurate Diagnosis
Having a solid understanding of anatomy and knowing the severity of the patient's situation give your coding a firm foundation.
Define it: The labrum is the rim of cartilage that deepens the shoulder socket (glenoid) and increases joint stability. The superior portion of the labrum can be torn when the shoulder dislocates forwardly (anteriorly). This results in a SLAP lesion — a tear of the superior labrum, anterior to posterior, says William J. Mallon, MD, an orthopedic surgeon and medical director of Triangle Orthopaedic Associates in Durham, N.C.
Patients can acquire a SLAP lesion after falling down, or following repeated overhead actions such as throwing a football. Symptoms include pain, swelling, and an occasional “clicking� sound when moving the arm in a throwing position.
Diagnose it: The diagnosis you submit depends on the physician's clinical diagnosis and whether the injury is acute or chronic. Two of the most common diagnoses you'll encounter are:
• For acute injuries, use 840.7 (Sprains and strains of shoulder and upper arm; superior glenoid labrum lesion) . “Code 840.7 requires an injury date, so be sure the physician notes it in the patient record,â€� Mallon says.
• Code 718.01 (Articular cartilage disorder; shoulder region) applies to chronic or degenerative injuries.
Avoid this: Coders sometimes report 718.81 (Other joint derangement, not elsewhere classified; shoulder region) for SLAP lesions, but that's not your best choice because the labrum is not articular cartilage. 718.01 is more accurate for chronic or degenerative SLAP lesions for instability.
Verify Injury's Severity to...
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