Find information on left clavicle pain diagnosis, including clinical documentation, medical coding (ICD-10, SNOMED CT), differential diagnosis, and common causes like fractures, dislocations, and acromioclavicular joint injuries. Learn about examination techniques, treatment options, and appropriate medical terminology for accurate healthcare records. Explore resources for physicians, coders, and other healthcare professionals related to left clavicle pain management and documentation.
Also known as
Pain in joint, left shoulder
Encompasses pain specifically in the left shoulder joint.
Pain in left shoulder region
Covers pain in the broader left shoulder area, not limited to the joint.
Fracture of left clavicle
If a fracture is the cause of pain, this code is more specific.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the left clavicle pain traumatic in origin?
Yes
Is there a fracture?
No
Is there another specific diagnosis?
When to use each related code
Description |
---|
Left clavicle pain |
Left AC joint injury |
Left sternoclavicular pain |
Coding left clavicle pain without specifying laterality can lead to claim rejections. Documentation must clearly indicate "left" side.
Coding pain without an underlying diagnosis risks claim denial. CDI should query physicians for root cause of left clavicle pain.
Distinguishing traumatic from non-traumatic left clavicle pain is crucial for accurate coding and affects reimbursement. Proper documentation is key.
Patient presents with left clavicle pain. Onset of pain was (onset date or duration e.g., two weeks ago, gradual onset). The patient describes the pain as (character of pain e.g., sharp, dull, aching, burning, throbbing) and localized to the (specific location e.g., medial clavicle, distal clavicle, left sternoclavicular joint, left acromioclavicular joint). Pain is aggravated by (aggravating factors e.g., movement, palpation, lifting, overhead activities) and relieved by (relieving factors e.g., rest, ice, heat, medication). Patient denies (negative symptoms e.g., fever, chills, numbness, tingling, radiating pain down the arm). Patient reports (positive symptoms, if any, e.g., clicking, popping, swelling, bruising, limited range of motion). Medical history includes (relevant medical history e.g., prior clavicle fracture, history of arthritis, osteoporosis). Social history includes (relevant social history e.g., occupation, dominant hand, sports activities). Physical examination reveals (objective findings e.g., tenderness to palpation over the left clavicle, crepitus, deformity, swelling, ecchymosis, limited range of motion of the left shoulder). Neurovascular examination of the left upper extremity is intact (include specific sensory and motor testing results if performed). Differential diagnosis includes (differential diagnoses e.g., clavicle fracture, acromioclavicular joint sprain, sternoclavicular joint sprain, osteoarthritis, distal clavicular osteolysis, thoracic outlet syndrome). Assessment: Left clavicle pain, likely (most likely diagnosis). Plan: (plan of care e.g., Obtain (imaging studies ordered, e.g., left clavicle x-ray, left shoulder x-ray), prescribe (medications prescribed, e.g., NSAIDs), recommend (recommendations e.g., rest, ice, physical therapy), patient education regarding (education provided e.g., activity modification, pain management strategies). Follow-up in (duration e.g., one week, two weeks) to reassess.