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General Surgery Coding Alert

General Surgery Coding:

Don’t Report an Open Fracture Repair Code Without Documentation

Published on Mon Mar 30, 2026

Question: A patient came in for surgery to repair a percutaneous intra-articular proximal phalanx head fracture. Here is a portion of the op note: The patient was taken back to the OR and underwent anesthesia without complication. The right upper extremity was prepped and draped in the usual sterile fashion. A time-out occurred immediately prior to procedure identifying the correct [...]
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