mardi 3 mars 2015

septic shoulder joint

Pt is seen in followup from rehab for shoulder. Exam shows "severely infected" left shoulder, with odor, draining pus. Assessment is "shoulder joint pain, septic left shoulder joint." Pt is advised to go to ER for debridement and IV antibiotics. No treatment or labs are ordered.

Doc has chosen 719.41 (shoulder pain) as diagnosis, but I'm wondering if I need to code more specifically to address "septic," or if there is really enough information (e.g., organism) provided in this short SOAP note.


In the index, Infection, joint, leads me to 711.01...but does this cover sepsis, or does a sepsis diagnosis require more workup? How would you code this? (Newbie here, still learning lots!)






septic shoulder joint

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