Lack of Primary Diagnosis

proddy@clarionhospital.org

Need some help on what to do in this circumstance.  The patient came swelling and tenderness of her knee s/p arthroscopy the day prior.  They suspected infection and arthrocentesis done in the ER, however the cultures are all negative.  Vitals on admission 98.6, 101, 22  (t max after admission101.2) WBC 16.5.The progress notes are using pain in knee as the primary dx. On discussion with the attending she said she is really at a loss on what to use since infection was ruled out.  The ER had referred to a knee effusion, would you use that?

bbogda@morrishospital.org

Was she given antibiotics for suspected infection?  Could you use B99.9 Other infectious disease (869 other infectious & parasitic diseases diagnosis)?  She had a temp, tachycardia, tachypnea, and leukocytosis so seems like something was going on.  If her symptoms improved or resolved with antibiotics, I would think that 869 would work since it includes Unidentified Infectious Process with the potential source of her knee.  Unless of course they are relating the inflammatory process to the procedure, then you are looking at Post procedural complication?

proddy@clarionhospital.org

They actually did not have her on an IV antibiotic.  The surgeon documents he feels she is tolerant to the effects of pain meds and as the procedure is known to be painful for a couple of days, he thinks it was normal post op. He didn't specifically account for her temp.  

bbogda@morrishospital.org

How about Post procedural pain NOS (G89.18) DRG 948 rw 0.7356.   

proddy@clarionhospital.org

the attending ended up going with Right Knee effusion and the post procedural pain as a secondary.  I don't see an authorization # in the account yet, so if may change to observation, but often they don't know that until several days after discharge