traumatic vs spontaneous

Hi group. Looking for all any and all opinions on this topic.
What is the definition of Traumatic tear/rupture vs Spontaneous tear/rupture?

Here's why I ask:  Patient comes in with a quad tear/rupture. "he played a game last Friday and planted his right foot, it gave out and he collapsed. He has been unable to bear weight or hold his leg out against gravity since then."   Is this truamtic or spontaneous?

Patient was placed in a TROM for immobilization - - Medicare's LCD that shows which dxs are payable under this DME is listing only the spontaneous dx ('M" codes) -  - why would the traumatic ("S" injury codes ie sprain/strain) not be payable? 


Secondly, should we always code the spontaenous  dx even if it's an injury occuring during an activity so the DME is payable?   (This just seems wrong to me however, the patient needs the DME regardless and I'm sure the patient doesn't want billed for the entire DME fee)


Thnak you for your time.

Comments

  • In ICD-10 spontaneous equates to non-traumatic....
  • In ICD10 spontaneous equates with non-traumatic
  • This is a traumatic rupture due to the injury. A spontaneous rupture would be if the tendon ruptured from a degenerative process without injury. As far as billing the DME with an incorrect diagnosis for reimbursement, that is fraudulent and not correct coding. If your claim denies then you will have to appeal.
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