tci Part B Insider - 2009 Issue 29

READER QUESTION: Consider Two Different Ways to Possibly Code Complaint From Past Injury

Tip: Determine whether prior conditions contribute to the patient's current complaint before you add the diagnosis codes. Question: We have a patient with a previous injury to the spine that is now causing neck pain. How should I code the diagnosis? Answer: Document and code prior conditions that contribute to a patient's current complaint -- if they affect the management of the current condition. Prior trauma, such as a previously broken bone or other injury, can cause patients to experience back pain. If the patient's pain stems from a previous condition, you may code that diagnosis to justify pain...

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