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

May 19, 2010

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 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

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