Cracking the Code
Coding Tips: Sequencing Multiple Injuries
When a patient presents to the hospital for treatment of multiple injuries, it is appropriate to code all of the injuries for accurate reporting purposes. All of the injuries should be reported separately unless there is a combination diagnosis code provided for those conditions. The injury that is sequenced first is the injury that is determined by the physician and focus of treatment to be the most serious.
Q: A 45-year-old patient presents to the ED with complaints of left shoulder, leg and ankle pain after falling off a ladder while painting her home. The physician places orders for x-rays. The imaging results reveal a pilon fracture of the left tibia and a sprain of the left AC joint of the shoulder. The patient is discharged home with a splint applied to the left foot.
A: S82.872A, Displaced pilon fracture of left tibia, initial encounter for closed fracture – primary diagnosis S43.52XA, Sprain of left acromioclavicular joint, initial encounter – secondary diagnosis
Reference: ICD-10-CM Official Guidelines for Coding and Reporting FY 2020 Ch. 19 Section b.