Bernadette Posted Tue 06th of May, 2014 13:55:20 PM
A teenaged, pediatric patient came in for a wellness exam and the pediatrician examined her spine. The patient's spine was normal but she noticed that the left shoulder was higher than her right.It is more of a muscular than skeletal difference. Is there an IDC-9 code that would be suitable to use for this finding?
SuperCoder Answered Tue 06th of May, 2014 17:18:37 PM
728.3 seems good here.
"more of a muscular than skeletal difference"
Bernadette Posted Wed 07th of May, 2014 09:39:18 AM
Let me clarify some of the information. The patient carries a back pack on her right and left shoulder but carries her golf bag on her right shoulder. Though the patient is not experiencing pain, spasm or any other symptom, her left shoulder looks higher than her right. She does not have scoliosis and her scapula look good. It is more of the trapezius muscle on right side is lower than the left due to the weight of the back pack and golf clubs when she carries them.
Is there another IDC-9 suitable for this situation?
728.3 does not seem appropriate for this matter.
SuperCoder Answered Thu 08th of May, 2014 05:56:14 AM
If she has no pain and no scoliosis I don't think there is a diagnosis, or a diagnosis code.