ICD-10 Codes and Documentation Tips for Shoulder Dislocation

Hello and welcome to our podcast series. My name is Meghann Drella and I’m a Senior Solutions Manager here at Outsource Strategies International (OSI). Today we’ll be discussing 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, documentation and correct ICD-10 code assignment is necessary.

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 the most 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
• Numbness in the arm
• Bruising and swelling and
• Change in the shape of the shoulder or
• Muscle weakness

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.

When the clinical documentation indicates a subluxation or dislocation of the shoulder joint, ICD-10 codes in the S43- series 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 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
• 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 or
• 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:

• Subluxation, which is a partial of incomplete dislocation of the joint
• Dislocation, which is a complete dislocation of the joint or luxation of the joint, and
• Percentage, which is a percentage of the dislocation

The reason for the visit or the type of encounter: documentation should identify the type of visit associated with new or healing injuries such as, an initial visit for Emergency Department encounter, subsequent visit for aftercare and follow-up, 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.

The clinical documentation should also include the following notes:

• Cause of the injury
• Identify it as being confirmed, suspected or ruled out
• Clarify the intention or patient mindset surrounding the injury
• The location of the patient when the injury occurred
• The activity of the patient at the time of the injury, and
• The work status of the patient at the time of the injury

The ICD-10 code for shoulder dislocation is S43. The ICD-10 codes for shoulder dislocations consist of seven characters.

Please see the list of codes in the attached article.

I hope this helps, but always remember that documentation as well as a thorough knowledge of payer regulations and guidelines is critical to ensure accurate reimbursement.

Thank you for joining me and stay tuned for my next podcast.