tci ED Coding & Reimbursement Alert - 2017 Issue 4

You Be the Coder: Watch for Age and Provider in Assigning Your Moderate Sedation Codes

Question:Chief Complaint: Shoulder pain, Injury to left shoulderHistory of Present Illness: Patient is a 15 year-old male who presents to the ED for evaluation after an injury to the left shoulder just PTA. He was wrestling with a friend and he was slammed to the floor. States he felt a "pop" in his left shoulder. States he did hit his head but no LOC. Pain rated as 8/10. There are no other complaints at this time.ROS: Constitutional: Negative. Cardiovascular: Negative. Musculoskeletal: Left shoulder pain.ROS: All systems are reviewed and are negative except as noted in the HPI...

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