Shoulder Dislocation – ICD-10 Codes and Documentation Tips

The shoulder joint is a ball-and-socket joint. Dislocation of the shoulder joint occurs when the humerus (the top of the upper arm bone) moves partially or fully out of the glenoid (shoulder socket bone). As the shoulder is the most mobile joint in the body, shoulder dislocations form about 50 percent of joint dislocations, with anterior dislocation being the most common type. While diagnosing a shoulder dislocation is fairly straightforward, thorough documentation and correct ICD-10 code assignment is necessary for better, more effective patient care. Physicians can rely on medical billing and coding services to report the condition correctly on claims and receive reimbursement for services.

Causes and Symptoms

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A dislocated shoulder occurs when the bones are pulled of their place in the socket by a strong force such as a blow to the joint or extreme rotation. Contact sports, falls, and motor vehicle accidents are common causes of shoulder dislocation. Seizures and electric shock are other causes of this joint injury.

Symptoms of a dislocated shoulder include:

• Severe pain
• Decreased range of motion of the shoulder
• Numbness in the arm
• Bruising and swelling in the shoulder area
• Change in the shape of the shoulder
• Muscle weakness

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Diagnosis and Treatment

A thorough medical history and physical examination are conducted to diagnose a shoulder dislocation. Imaging tests may be also recommended to confirm the nature and extent of the dislocation and the maneuver needed to perform “reduction” or moving the joint back to its correct position. There are various reduction techniques and the physician will use the most suitable one based on the nature of the dislocation.

ICD-10 Coding and Clinical Documentation

When the clinical documentation indicates a subluxation or dislocation of the shoulder joint, ICD-10 codes in the S43- series (dislocation and sprain of joints and ligaments of -shoulder girdle) offer increased specificity to report the condition.

To enable coders to assign the correct ICD-10 codes, the documentation should specify the positioning, location of the dislocation including laterality (right or left), joint involved, the extent of the dislocation, and encounter.

• Positioning and Location: There are three different types of shoulder dislocations:
  • Anterior – The top of the humerus is displaced forward, toward the front of the socket. This is the most common type of shoulder dislocation
  • Posterior – In this case, the head of the arm bone is moved behind and above the socket. This is an uncommon type that is caused by seizures or an electric shock.
  • Inferior – This is rarest type of shoulder dislocation where the top of the humerus is displaced downward. It occurs when the arm is pushed downward violently.
• Extent of the dislocation: An AAPC article notes that the extent of the dislocation can be defined in several ways (www.aapc.com):
  • Subluxation – Partial of incomplete dislocation of joint
  • Dislocation – Complete dislocation of the joint or luxation of the joint
  • Percentage – Percentage of the dislocation
• Reason for the visit (type of encounter): The documentation should identify the type of visit associated with new or healing injuries (such as, initial visit for ED encounter, subsequent visit for aftercare and follow-up, sequela (or late effect) visit for complications or other conditions that arise as a direct result of another condition, after the acute phase of a condition has subsided.

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The clinical documentation should also include the following, notes www.choa.org:

• Cause of the injury (e.g. car accident, fall down stairs)
• Identify it as being confirmed, suspected or ruled out
• Clarify the intention or patient mindset surrounding the injury (e.g. accidental, assault, self-inflicted, undetermined)
• The location of the patient when the injury occurred (e.g., school baseball field)
• The activity of the patient at the time of the injury (e.g. playing baseball)
• The work status of the patient at the time of the injury (recreation, school sport)

The ICD-10 code for shoulder dislocation is S43 Dislocation and sprain of joints and ligaments of shoulder girdle.

The ICD-10 codes for shoulder dislocations consist of seven characters. The seventh character denotes the encounter (initial, subsequent, or sequela). Unspecified” codes are used when no information is available to support a more specific code:

S43.001A Unspecified subluxation of right shoulder joint, initial encounter S43.001D Unspecified subluxation of right shoulder joint, subsequent encounter S43.001S Unspecified subluxation of right shoulder joint, sequela S43.002A Unspecified subluxation of left shoulder joint, initial encounter S43.002D Unspecified subluxation of left shoulder joint, subsequent encounter S43.002S Unspecified subluxation of left shoulder joint, sequela S43.003A Unspecified subluxation of unspecified shoulder joint, initial encounter S43.003D Unspecified subluxation of unspecified shoulder joint, subsequent encounter S43.003S Unspecified subluxation of unspecified shoulder joint, sequela S43.004A Unspecified dislocation of right shoulder joint, initial encounter S43.004D Unspecified dislocation of right shoulder joint, subsequent encounter S43.004S Unspecified dislocation of right shoulder joint, sequela S43.005A Unspecified dislocation of left shoulder joint, initial encounter S43.005D Unspecified dislocation of left shoulder joint, subsequent encounter S43.005S Unspecified dislocation of left shoulder joint, sequela S43.006A Unspecified dislocation of unspecified shoulder joint, initial encounter S43.006D Unspecified dislocation of unspecified shoulder joint, subsequent encounter S43.006S Unspecified dislocation of unspecified shoulder joint, sequela

Providing the necessary information and using the specific terminology in the clinical documentation is essential to help a medical billing and coding company translate patient encounters into the correct ICD-10 codes for claims submission and reimbursement.

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