Health Information Management

Q&A: Coding for arm pain and swelling after splint placement

JustCoding News: Outpatient, June 16, 2010

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QUESTION: A patient came in with arm pain and swelling after splint placement for an elbow fracture. The physician replaced her long splint with a short splint. Is this a complication of splint or should we just use a pain code?

ANSWER: Pain and swelling are both component signs of inflammation and infection. In the case you briefly described, the external device was the cause of the inflammation. If so and the physician originally placed the splint postoperatively, then ICD-9-CM code 998.89 (postoperative infection, other specified complications of procedures) may be the most accurate code to report. If there was no surgical procedure preceding the application of the splint, ICD-9-CM code 999.9 (misadventure of medical care), may be the appropriate choice.

Check the physician’s notes or query the physician to more clearly identify the cause of the inflammation. Doing so may help guide you to the accurate code.

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at

This answer was provided based on limited information submitted to Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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