Dr. Marks (Karen Zupko & Associates) presented an on site seminar for our office last month. The information provided on this topic was that the encounter was for pain control as opposed to treating the underlying condition (OA). According to the guidance from the seminar, we were instructed to sequence pain first followed by the underlying condition. Reminder: this can never be assumed based on the number of visits for pain management and it must be clearly documented in the note.

Personally, I break it down by thinking that the Kenalog, celestone, or whatever medication isn’t used to treat OA but used to alleviate the symptoms related to the OA. It was hard for me to wrap my brain around this at first because we are not permitted to report signs and symptoms if we have a definitive dx, but that specific procedure was for the symptom specifically. (I hope that makes sense)

If you haven’t been on the Karen Zupko website, it is a great resource! They have the option of submitting coding questions as well.