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How to code DX for tears when document provides mising info about Traumatic or degenerative?
When we go by index, it leads to Traumatic as first, so should we go with the traumatic codes? or we should also check the patient age with comorbids inculding degenrative diseases (OA, Bursitis, Chondramalacia etc.) to code for degenerative tears if not mentioned as trauma?
Please provide any approved guidelines if possible. Thank you…:o
Case # 1
SUBJECTIVE: **** is here today for evaluation of her left knee. *** has had left knee pain ever since mid-December. Prior to that she did not have any significant pain or problems and was able to ambulate without much difficulty. Now she has snapping, popping and significant pain to the lateral and posterolateral aspects of the knee, near locking episodes and the knee is unsteady for her although there is no gross instability complaints.
PLAN: At this time she does have some early degenerative changes as well as a lateral meniscal tear. However, I think she has lived with the degenerative changes for quite some time and the new onset of the lateral meniscal tear is quite symptomatic. Therefore, we have talked with her about treatment options. We have gone over the risks, complications, as well as benefits and expectations of surgery, postop protocol and follow-up. We will get this set up as soon as possible. Will get her medically cleared and I’ll see her back at the time of surgery. Until then, she will continue with ice, elevation, modification of activities, etc.
Janet Beck, CPC
Exam says "the patient has a wound on the left anterior shin with exposed tendon. left foot is warm and well perfused. Palpable left femoral pulse. Nonpalpable popliteal pulse and nonpalpable pedal pulses."
Patient is elderly; is a current tobacco user, and has chronic lower extremity edema. Patient has not been seen previously by this medical group.
I’ll probably use S89.92X_, but is an A or an S more accurate? The wound has been seen and treated, just not by this practice, and after 3 weeks it should be healing, not increasing in size.
In this particular case, the provider gave information about the etiology, duration, depth, and location of the wound. Usually the reports from this office just say that there’s a non-healing wound on the left (or right) lower extremity. Is it best to just use L97.819/L97.829 in that case?