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Question: A patient presented to their primary care physician (PCP) with left shoulder pain that has persisted for three weeks. The patient attested that they collided with another player and fell during a soccer game three weeks earlier. The PCP ordered shoulder X-rays, which were negative for fractures and other injuries. The patient exhibited no other visible signs of injury, such as bruising or abrasions.

Should we use a shoulder pain or an unspecified left shoulder injury diagnosis code to represent the condition?

South Dakota Subscriber

Answer: You should use a shoulder pain code, such as M25.512 (Pain in left shoulder), to report this claim. The patient has experienced the pain for three weeks following the fall during the soccer game, and it is the chief complaint for the visit, regardless of the negative X-ray results. While the shoulder X-rays were negative, that doesn’t completely rule out an injury or another underlying issue. The negative results simply mean the interpreting physician did not detect any fractures or dislocations.

Assigning S40.912A (Unspecified superficial injury of left shoulder, initial encounter) is tempting given the patient is in pain, experienced a fall, and there aren’t any visible signs of injury. However, the code isn’t appropriate because an unspecified injury code is usually assigned when the patient clearly has an injury, but the documentation doesn’t call out key information like the nature of the injury or its severity.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC