Medical Coders: Don’t Let Shorthand Block You From Correct Code

If you have a question, be sure to ask your physician.

Question: A patient reports to the ER at 8 a.m. on a Sunday morning. He reports a horrible toothache that started on Friday; he says he planned to “tough it out” over the weekend and see his dentist Monday, but the pain was too severe; he reports 10 on a 10-point pain scale. The ER physician performs an “inf. Aveo block,” according to the notes. What condition do the notes reflect, and how should I code this scenario?

Massachusetts Subscriber

Answer: You should double-check with the physician before filing...

If you have a question, be sure to ask your physician.

Question: A patient reports to the ER at 8 a.m. on a Sunday morning. He reports a horrible toothache that started on Friday; he says he planned to “tough it out” over the weekend and see his dentist Monday, but the pain was too severe; he reports 10 on a 10-point pain scale. The ER physician performs an “inf. Aveo block,” according to the notes. What condition do the notes reflect, and how should I code this scenario?

FasterCoder Advertisement

Massachusetts Subscriber

Answer: You should double-check with the physician before filing the claim, but the shorthand appears to indicate that he performed an inferior Aveolar block, which is a type of dental block. If the physician confirms this procedure, report the following:

  • 64400 (Injection, anesthetic agent; trigeminal nerve, any division or branch) for the block
  • 525.9 (Unspecified disorder of the teeth and supporting structures) appended to 64400 to represent the patient’s condition.

Emergency Department Coding Alert, Editor: Chris Boucher, CPC

Want to know more? Sign up for the upcoming live audio conference, Take the Sting out of Coding Infusion and Injection Services, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

CPC Exam Study Guide
CCA Exam Study Guide
CCS Exam Study Guide
CPB Exam Study Guide
CRC Exam Study Guide
Facebook
Twitter
LinkedIn
Pinterest